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First National Bank of Pasco
Certificate of Deposit Application

Privacy Policy:
Our privacy policy protects the privacy of your personally-identifying information that you provide us online.

Important Information about Procedures for Opening a New Account
Identification Procedures Requirements: To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account.

What this means for you: 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.

Security Notice:
You should ONLY fill out this Application on-line if you are using a browser with the latest security enhancements. If you don't have the latest version, download a copy now.

Instructions:
1. Complete Application and click "Submit Application" or fax it to 352-567-1777.
2. To safeguard your privacy, QUIT your browser and restart it again after using this form. This form is NOT saved in your computer's memory when you quit your browser.
3. We will contact you with the location of our closest office for you to sign a signature card. You will also need to provide photocopies of your Social Security card and Driver's License, or other documentation.

Primary Joint Account Holder Information
First Name
Middle Initial
Last Name
Home Phone
Date of Birth
Place of Birth
Social Security No.
Your E-mail Address
Driver's License No.
Driver's License State
Date Issued
Expiration Date
Street Address
City
State
Zip
Subject to backup withholding Y NWork Phone
Mother's Maiden Name
Joint Account Holder(with right of survivorship)
First Name
Middle Initial
Last Name
Home Phone
Date of Birth
Place of Birth
Social Security No.
Your E-mail Address
Driver's License No.
Driver's License State
Date Issued
Expiration Date
Street Address
City
State
Zip
Subject to backup withholding Y NWork Phone
Mother's Maiden Name
Account Titling Information
Individual
Joint
In Trust ForName
Social Security No.
CustodialName
Social Security No.

I/We would like to apply for the following
Certificate of Deposit:

TermAmount
3 month$
6 month$
9 month$
1 year$
2 year$
3 year$
5 year$


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).

Certification 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 National Bank of Pasco within sixty (60) days, then First National Bank of Pasco 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.

I 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 National Bank of Pasco.

I/We AGREE with the above statement