Enter the name(s) of the convenience signer(s), if you want one or more convenience signers on this account: (1239)

Transcription

1 Sec FORM. A financial institution may use the following form to establish the type of account selected by a party: (1233) UNIFORM SINGLE-PARTY OR MULTIPLE-PARTY ACCOUNT SELECTION FORM NOTICE: The type of account you select may determine how property passes on your death. Your will may not control the disposition of funds held in some of the following accounts. You may choose to designate one or more convenience signers on an account, even if the account is not a convenience account. A designated convenience signer may make transactions on your behalf during your lifetime, but does not own the account during your lifetime. The designated convenience signer owns the account on your death only if the convenience signer is also designated as a P.O.D. payee or trust account beneficiary. (1234) Select one of the following accounts by placing your initials next to the account selected: (1235) (1) SINGLE-PARTY ACCOUNT WITHOUT "P.O.D." (PAYABLE ON DEATH) DESIGNATION. The party to the account owns the account. On the death of the party, ownership of the account passes as a part of the party's estate under the party's will or by intestacy. (1236) Enter the name of the party: (1237) (1238) more convenience signers on this account: (1239) (1240) (1241) (2) SINGLE-PARTY ACCOUNT WITH "P.O.D." (PAYABLE ON DEATH) DESIGNATION. The party to the account owns the account. On the death of the party, ownership of the account

2 passes to the P.O.D. beneficiaries of the account. The account is not a part of the party's estate. (1242) Enter the name of the party: (1243) (1244) Enter the name or names of the P.O.D. beneficiaries: (1245) (1246) (1247) more convenience signers on this account: (1248) (1249) (1250) (3) MULTIPLE-PARTY ACCOUNT WITHOUT RIGHT OF SURVIVORSHIP. The parties to the account own the account in proportion to the parties' net contributions to the account. The financial institution may pay any sum in the account to a party at any time. On the death of a party, the party's ownership of the account passes as a part of the party's estate under the party's will or by intestacy. (1251) Enter the names of the parties: (1252) (1253) (1254) (1255) more convenience signers on this account: (1256)

3 (1257) (1258) (4) MULTIPLE-PARTY ACCOUNT WITH RIGHT OF SURVIVORSHIP. The parties to the account own the account in proportion to the parties' net contributions to the account. The financial institution may pay any sum in the account to a party at any time. On the death of a party, the party's ownership of the account passes to the surviving parties. (1259) Enter the names of the parties: (1260) (1261) (1262) more convenience signers on this account: (1263) (1264) (1265) (5) MULTIPLE-PARTY ACCOUNT WITH RIGHT OF SURVIVORSHIP AND P.O.D. (PAYABLE ON DEATH) DESIGNATION. The parties to the account own the account in proportion to the parties' net contributions to the account. The financial institution may pay any sum in the account to a party at any time. On the death of the last surviving party, the ownership of the account passes to the P.O.D. beneficiaries. (1266) Enter the names of the parties: (1267) (1268) (1269)

4 Enter the name or names of the P.O.D. beneficiaries: (1270) (1271) (1272) more convenience signers on this account: (1273) (1274) (1275) (6) CONVENIENCE ACCOUNT. The parties to the account own the account. One or more convenience signers to the account may make account transactions for a party. A convenience signer does not own the account. On the death of the last surviving party, ownership of the account passes as a part of the last surviving party's estate under the last surviving party's will or by intestacy. The financial institution may pay funds in the account to a convenience signer before the financial institution receives notice of the death of the last surviving party. The payment to a convenience signer does not affect the parties' ownership of the account. (1276) Enter the names of the parties: (1277) (1278) (1279) Enter the name(s) of the convenience signer(s): (1280) (1281) (1282)

5 (7) TRUST ACCOUNT. The parties named as trustees to the account own the account in proportion to the parties' net contributions to the account. A trustee may withdraw funds from the account. A beneficiary may not withdraw funds from the account before all trustees are deceased. On the death of the last surviving trustee, the ownership of the account passes to the beneficiary. The trust account is not a part of a trustee's estate and does not pass under the trustee's will or by intestacy, unless the trustee survives all of the beneficiaries and all other trustees. (1283) Enter the name or names of the trustees: (1284) (1285) (1286) Enter the name or names of the beneficiaries: (1287) (1288) (1289) more convenience signers on this account: (1290) (1291) (1292) Amended by: (1293) Acts 2011, 82nd Leg., R.S., Ch. 91, Sec , eff. January 1, (1294) Text of section effective on January 01, 2014 (1295)

6 NEW ACCOUNT APPLICATION Type of Account Applying for Purpose of Account Consumer Business Who Recommended Us to You? ATM CASH CARD REQUEST PIN # (Caution: For security reasons do not select your SSN, of Birth or other separately discoverable number as the PIN.) Number of Cards Requested Checking Account No. Number of Cards Received Savings Account No. OWNERSHIP OF ACCOUNT Not all forms of ownership may be allowed in your state. Check with your financial institution. Individual Joint - With Survivorship Joint - No Survivorship (and not as tenants in common) (as tenants in common) Revocable Trust or Pay-On-Death Beneficiary Name Address Name Address Unincorporated Nonbusiness Association of Individuals Sole Proprietorship Partnership Limited Liability Company Corporation: For Profit Not For Profit Business County and State of Organization: Separate Authorization Received Yes No Facsimile Signature Yes No Name (Last, First, Middle) INDIVIDUAL APPLICANT INFORMATION FOR INSTITUTION USE Account No. Approved By Declined By Checking Money Market TYPE OF ACCOUNT Savings CD NOW Initial Deposit $ Cash Check No. Additional Information Birth Home Telephone No. Drivers Lic. No. / Passport No. Social Security No. / / Present Address (Street, City, State & Zip) Do You Own County How Long or Rent Permanent Address County How Long Employer How Long Address Position/Title Telephone No. Previous Employer (If Current Employer is Less Than Years) How Long Address Position/Title Telephone No. Name and Address of Nearest Relative Not Living With You Relationship Telephone No. JOINT APPLICANT INFORMATION Name (Last, First, Middle) Relationship Birth Telephone No. Drivers License No. Social Security No. / / Address (Street, City, State & Zip) Employer How Long Address Position Telephone No. Name and Address of Nearest Relative Not Living With You. Relationship Telephone No. C 1992 Bankers Systems, Inc., St. Cloud, MN Form NAAP 7/11/2001 (page 1 of 2)

7 FINANCIAL INSTITUTION RELATIONSHIPS Name of Financial Institution and Address Type of Account BANK OR OTHER CREDIT CARDS Company Account No. Credit Limit Balance BACKUP WITHHOLDING CERTIFICATIONS TAXPAYER I.D. NUMBER - My correct taxpayer identification number is: APPLIED-FOR TAXPAYER I.D. NUMBER - A taxpayer identification number has not been issued to me, and I mailed or delivered an application to receive a taxpayer identification number to the appropriate Internal Revenue Service Center or Social Security Administration Office (or I intend to mail or deliver an application in the near future). I understand that if I do not provide a taxpayer identification number to the payor within 60 days, the payor is required to withhold the percentage allowed under the Internal Revenue Code of all reportable payments thereafter made to me until I provide a number. EXEMPT RECIPIENTS - I am an exempt recipient under the Internal Revenue Service Regulations. (See below.) BACKUP WITHHOLDING - 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. NONRESIDENT ALIENS - A separate certification has been or will be completed. SIGNATURE: I certify under penalties of perjury the statements checked in this section and that I am a U.S. person (including a U.S. resident alien). DATE Payees Exempt from Backup Withholding We are not required to backup withhold if the payee is: An organization exempt from tax under section 501(a) or an individual retirement plan. The United States or any of its agencies or instrumentalities. A state, the District of Columbia, a possession of the United States, or any of their political subdivisions, or instrumentalities. A foreign government or any of its political subdivisions, agencies, or instrumentalities. An international organization or any of its agencies or instrumentalities. Other payees that may be exempt from backup withholding include: A corporation. A foreign central bank of issue. A dealer in securities or commodities required to register in the United States, the District of Columbia, or a possession of the United States. A futures commission merchant registered with the Commodity Futures Trading Commission. A real estate investment trust. An entity registered at all times during the tax year under the Investment Company Act of A common trust fund operated by a bank under section 584(a). A financial institution. A middleman known in the investment community as a nominee or custodian. A trust exempt from tax under section 664 or described in section Payments of interest not generally subject to backup withholding include the following: Payments of interest on obligations issued by individuals. Note: You may be subject to backup withholding if this interest is $600 or more and is paid in the course of the payer s trade or business and you have not provided your correct taxpayer identification number to the payer. Payments of tax-exempt interest (including exempt interest dividends under section 852). Payments described in section 6049(b)(5) to nonresident aliens. Payments on tax-free covenant bonds under section Payments made by certain foreign organizations. Payments of mortgage or student loan interest. Payments that are not subject to information reporting are also not subject to backup withholding. For details, see the regulations under sections 6041, 6041A, 6045, 6050A, and 6050N. SIGNATURES The undersigned acknowledge(s) receipt of a copy of and agree(s) to the terms of the following disclosure(s): Truth in Savings Electronic Funds Transfer Funds Availability Privacy I certify that everything I have stated in this application and on any attachments is correct. You may keep this application whether or not it is approved. By signing below I authorize you to check my credit account and employment history and/or have a credit reporting agency prepare a credit report on me, as an individual. I also authorize you to answer questions others may ask you about my credit record with you. I understand that I must update credit information at your request if my financial condition changes. Applicant s Signature Joint Applicant s Signature Joint Applicant s Signature Joint Applicant s Signature Additional Authorized Signatories Signature Relationship/Title Signature Relationship/Title C 1992 Bankers Systems, Inc., St. Cloud, MN Form NAAP 7/11/2001 (page 2 of 2)