Ownership

Single Owner (individual)
Joint (right to survivorship)
Joint (no right to survivorship)
Payable on Death (POD)


Primary Account Owner

Name (First M. Last)
Date of Birth (mm/dd/yyyy)
Social Security Number:
Address
City, State Zip ,
Home Phone Number ( ) -
Work Phone Number ( ) -
Driver's License Number State
E-mail


Joint Account Owner (if you selected joint account ownership)

Name (First M. Last)
Date of Birth (mm/dd/yyyy)
Social Security Number
Driver's License Number State


Payable on Death Beneficiary (if you selected POD ownership)

Name (First M. Last)
Social Security Number
Phone Number ( ) -
Address
City, State Zip ,


Deposit Information

Initial Deposit $
Initial Deposit Type


Taxpayer Identification Number Certification

The Social Security Number(s) shown above is my correct SSN.

I am not subject to backup withholding either because I have not been notified that I am subject to backup withholding as a result of a failure to report all interest or dividends, or the Internal Revenue Service has notified me that I am no longer subject to backup withholding.

I am an exempt recipient under the Internal Revenue Service Regulations.

I am not a United States person, or if I am an individual, I am neither a citizen nor a resident of the United States.

I certify under penalties of perjury the statements checked in this section are true.
I authorize Fidelity State Bank and Trust Co. to obtain a copy of my current credit report as a condition of acceptance of this application and for the purpose of extension of or renewal of credit.
I (We) authorize you to write to that financial institution for my (our) references, and furnish them a copy of this account application. I (We) authorize that institution to respond to your inquiry.
I (We) also authorize you to order a credit report on me or make such other inquiries of investigative agencies as the bank deems advisable.
I (We) understand that the USA Patriot Act requires the bank to verify that I (We) are not on the OFAC SDN list, and that the bank may decline to open the account for any reason.
I would like to access this account through Online Banking.

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