The Internal Revenue Service
does not require your consent to any provision of this document other
than certification required to avoid backup withholding. See Taxpayer
Identification Number Certification below.
Taxpayer Identification Number Certification:
Under the 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, or (c) the IRS has notified me that I am
no longer subject to backup withholding as a result of failure to report
all interest or dividends, or (d) the IRS has notified me that I am no
longer subject to backup withholding, and (3) I am a U.S. person
(including U.S. resident alien).
Instructions: You must cross out item (2) above if you have been
notified by the IRS that you are currently subject to backup withholding
because of under-reporting interest or dividends on your tax return
unless you have received another notification form from the IRS that you
are no longer subject to backup withholding.
I understand that if I do not provide a taxpayer identification number to First Home Bank within sixty (60) days, then First Home Bank is required to withhold twenty percent (20%) of all reportable payments thereafter made to me until I provide a number.
By submitting this application,
I (each person jointly and severally) apply for the Certificate of
Deposit listed above. As a Certificate of Deposit owner, I am subject to
all of its bylaws and rules as amended from time to time. I certify
that all information given is correct.
agree to the terms and conditions for any accounts or services that I
have now or in the future, and as they change from time to time. I agree
at any time you may request information from others about my credit or
accounts and that you provide to others experience information about me
or my accounts with First Home Bank.
I/We AGREE with the above statement