Consumer Account Application Form – Fill Out and Use This PDF

Consumer Account Application

Bank name

To help the government fight the funding of terrorism and money laundering activities, U.S. Federal law requires financial institutions to obtain, verify, and record information that identifies each person (individuals and businesses) who opens an account. What this means for you: When you open an account, we will ask for your name, address, date of birth and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.

Request for Taxpayer Identification Number and Certification (Substitute Form W-9)

Certification: Under penalties of perjury, I certify that:

1)The number shown on this form is my correct Taxpayer Identification Number, and

2)UNLESS I HAVE CHECKED ONE OF THE BOXES BELOW, I am not subject to backup withholding either because I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or the IRS has notified me that I am no longer subject to backup withholding (does not apply to real estate transactions, mortgage interest paid, the acquisition or abandonment of secured property, contributions to an Individual Retirement Arrangement (IRA), and payments other than interest and dividends), and

3)I am a U.S. person (including a U.S. resident alien).

The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

NOTICE TO MARRIED APPLICANTS: No provision of any marital property agreement, unilateral statement under Sec.766.59 Wis. Stats, or a court decree under Sec.766.70 adversely affects the interest of the creditor unless the creditor, prior to the time the credit is granted, is furnished a copy of the agreement, statement or court decree or has actual knowledge of the adverse provisions when the obligation to the creditor is incurred.

Married Wisconsin resident applying individually (Customer 1) or married Wisconsin residents applying jointly, but not married to the other signer (Customer 1 and 2), please complete name and address of spouse on the separate Direct Deposit Advance Service - Wisconsin Marital Property Act (WMPA) Credit Notice to Spouse.

Joint Account with Right of Survivorship (Texas Only)

The persons signing this section hereby agree with each other and the bank that this account is a joint account with right of survivorship, and that on the death of one party to a joint account, all sums in the account on the date of death vest in and belong to the surviving party as his or her separate property and estate. Each person signing this section who is married to a person who is not also signing this section represents and warrants that no funds now or hereafter deposited to the account, nor any interest earned on such funds, are subject to the management, control or disposition (jointly or otherwise) of such person's spouse.

Signatures

Everything I have stated in this application is correct. You are authorized to make any inquiries that you consider appropriate to determine if you should open the account. This may include ordering a credit report or other report (i.e. information from any motor vehicle department or other state agency) on me. I have received a copy of the applicable account agreement and privacy brochure and agree to be bound by them, including the terms of the Direct Deposit

Advance® Service and Deposit AdvanceSM Service (Deposit Advance Service not available in all states) described in the Service Agreement and Product Guide. I also agree to the terms of the dispute resolution program described in the account agreement and Service Agreement and Product Guide. Under this program our disputes will be decided before one or more neutral persons in an arbitration proceeding and not by a jury trial or a trial before a judge.