Introductory BSA/AML Examiner School, Atlanta, CA

ACCOUNT NUMBER

ACCOUNT OWNER(S) NAME & ADDRESS

OWNERSHIP OF ACCOUNT - PERSONAL PURPOSE INDIVIDUAL JOINT - WITH SURVIVORSHIP (and not as tenants in common) JOINT - NO SURVIVORSHIP (as tenants in common) TRUST - SEPARATE AGREEMENT:

REVOCABLE TRUST

OR

PAY-ON-DEATH

DESIGNATION AS DEFINED IN THIS AGREEMENT

NEW

EXISTING SAVINGS

Name and Address of Beneficiaries:

TYPE OF ACCOUNT

CHECKING

MONEY MARKET

CERTIFICATE OF DEPOSIT

NOW This is your (check one): Permanent

Temporary

account agreement.

Number of signatures required for w ithdraw al FACSIMILE SIGNATURE(S) ALLOWED? YES

NO

[

]

OWNERSHIP OF ACCOUNT - BUSINESS PURPOSE

X

SOLE PROPRIETORSHIP CORPORATION:

SIGNATURE(S) - The undersignedcertifies the accuracy of the informationhe/she has provided and acknowledges receipt of a completed copy of this form. The undersigned authorizes the financial institution to verify credit and employment history and/or have a credit reporting agency prepare a credit report on the undersigned, as individuals. The undersigned also acknowledge the receipt of a copy andagreetothetermsof thefollowingagreement(s)and/or disclosure(s):

FOR PROFIT

NOT FOR PROFIT

PARTNERSHIP

BUSINESS:

COUNTY & STATE OF ORGANIZATION:

Terms & Conditions

Truth in Savings

Funds Availability Substitute Checks

AUTHORIZATION DATED:

Electronic Fund Transfers

Privacy

Common Features

DATE OPENED

BY

[ [ [ [

] ] ] ]

INITIAL DEPOSIT $ CASH HOME TELEPHONE # BUSINESS PHONE # DRIVER' S LICENSE # E-MAIL EMPLOYER

(1):

CHECK

X

I.D. #

D.O.B.

(2):

X

MOTHER' S MAIDEN NAME Name and address of someone who w ill always know your location:

I.D. #

D.O.B.

(3):

X

BACKUP WITHHOLDING CERTIFICATIONS

TIN:

I.D. #

D.O.B.

TAXPAYER I.D. NUMBER - The Taxpayer Identification Number shown above(TIN)ismy correct taxpayer identificationnumber. BACKUP WITHHOLDING - I amnot subject to backup withholding either becauseI havenot been notifiedthat I amsubject tobackupwithholding asaresult of a failureto report all interest or dividends, or theInternal RevenueServicehas notifiedme that I amnolonger subject tobackupwithholding. EXEMPT RECIPIENTS - I amanexempt recipient under theInternal Revenue ServiceRegulations. SIGNATURE: I certify under penaltiesof perjury thestatements checkedinthis section and that I am a U.S. citizen or other U.S. person (as defined in the instructions).

(4):

X

I.D. #

D.O.B.

Authorized Signer (Individual Accounts Only)

Joint Fiduciary

[

]

X

X

I.D.#

D.O.B.

(Date)

Signature Card-VT

MPSC-LAZ-VT 10/1/2009

Bankers Systems Wolters Kluw er Financial Services 1992, 2009

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