Personal Deposit Account Application

Thank you for your interest in First National Bank of Muscatine.

  Our general trade area is Muscatine County, Iowa and the surrounding contiguous counties.  We welcome all applications from our designated market area.

STEP 1 - PERSONAL INFORMATION

Choose an account type:
Checking:


Savings:

Ownership of Account:

    Individual
    Joint - with Survivorship (and not as Tenants in Common)
    Joint - no Survivorship (as Tenants in Common)
    Trust - Separate Agreement
    Pay-on-Death

 
Name:
Email Address:
 
Social Security Number
- - 		Date of Birth
(MM/DD/YYYY)
/ /
Home Phone
( ) - 		Mother's Maiden Name
Driver's License Number
or Registered ID
 State

If no Driver's License or Registered ID, Other ID Type:
Issued
(MM/DD/YYYY)
/ / 		Expires
(MM/DD/YYYY)
/ /

STEP 2 - ADDRESS INFORMATION
Residential Address ** (Required, not a P.O. Box)
City
   State
   Zip
Years There
Name of Someone who will always know your location:
Address:
City
 State

Zip

 

** If length of time at current address is less than two years, please complete the following:
Previous Address (Required, not a P.O. Box)
City
   State
   Zip
Years There

States Resided in Past 5 Years

 

Employer Name
Address
Work Phone and Extension
( ) -   
Length of Employment in Years:

STEP 3 - JOINT ACCOUNT HOLDER INFORMATION (IF APPLICABLE)
Name (Co-Applicant)
Social Security Number
- - 		  Birth Date
(MM/DD/YYYY)
/ /
Driver's License Number
or Registered ID
     State
Issued
(MM/DD/YYYY)
/ / 		  Expires
(MM/DD/YYYY)
/ /

Address (if different than above)

City
   State
   Zip

 

Employer
Address
Work Phone and Extension
( ) -   
Length of Employment in Years:

 

ADDITIONAL JOINT ACCOUNT HOLDER
Name (Co-Applicant)
Social Security Number
- - 		  Birth Date
(MM/DD/YYYY)
/ /
Driver's License Number
or Registered ID
     State
Issued
(MM/DD/YYYY)
/ / 		  Expires
(MM/DD/YYYY)
/ /
Address (if different than above)
City
   State
   Zip

 

Employer
Address
Work Phone and Extension
( ) -   
Length of Employment in Years:

APPLICANT TAXPAYER IDENTIFICATION NUMBER AND CERTIFICATION

(Please enter your Social Security Number or other Taxpayer Identification Number)

Certification Under penalties of perjury, I certify that:
1.  The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 
 
2.  I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) 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 (c) the IRS has notified me that I am no longer subject to backup withholding, and
 
3.  I am a U.S. person (including a U.S. resident alien).

Certification instructions. 

Do not  check next to item  2  above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return.  

 

Signature:

COMMENTS
 

Applicant Signature:

 
 
Date:
 

Co-Applicant Signature

 
 
Date:
 

Co-Applicant Signature

 
 
Date:
 

REMINDER: If you wish to send your application to us online, we want to remind you that e-mail applications are not necessarily secure against interception.  Applications, by their nature, include personal and confidential information such as your social security number and financial information.  Therefore, you may wish to consider printing the application, completing it, and sending it to us via U.S. postal mail. 

Once we receive this application we will be in touch with you to follow-up and receive your signature(s).

If you choose to print this application at this time, please select the landscape option in the "Page Setup" function for best viewing.

Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account in order to help the government fight the funding of terrorism and money laundering activities. This means that 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.

Updated 09/03

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300 E. 2nd St. | Muscatine, IA 52761
ph 563-263-4221 | fax 563-262-4213

© 2005-2006 First National Bank of Muscatine.  All rights reserved.