Primary Account Owner
Joint Account Owner (if you selected joint account ownership)
Payable on Death Beneficiary (if you selected POD ownership)
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.