EFTA01481218.pdf

0 CHASE PERSONAL SIGNATURE CARD AND APPLICATION JPMorgan Chase Bank IMO BRANCH COPY IIIIIIIiiiiirnt Title Primary Customer Information (Accounts with multiple owners are Joint, payable to either owner or the survivor.) 10021 ome Ph (000)000-0000 Account # Account Type CHASE EXTRA SAVINGS ACCOUNT Maiden Name Account An, INDIVIDUAL Birth Date /TIN Date Opened 02/19/2004 Opened By PHILLIP WALTERS Deposit Amt $0.01 This Account Is Not Transferable Please activate Check Coverage for the account listed above. I/we authorize you to Integrate and use as the 'Protecting Account(s)' the account(s) identified above on this application. I/we agree to the terms and conditions as contained in the Deposit Account Agreement and Disclosures. I/we agree that I/we have reviewed the information contained in this Personal Signature Card and Application and find it accurate on this date. In the payment of funds and in the transaction of all other business relative to this account, I/we agree that you are authorized to rely upon the signature(s) written below and on the --reverse-side.-1/we..have_received_and_agree_to_the_terms_and conditions of the Deposit Account Agreement and Disclosures currently in effect and as may be amended fur the type of -a-c-Co• wit and-seWic-es t.v3 ser; - EFTA01481218  above. If I/we do not have a Chase Banking Card, I/we will be issued one/two and all eligible accounts will be linked to it/them. These linked accounts, whether singly or jointly owned, can be accessed by the Chase Banking Card or by telephone. During the review of my/our application, you may obtain a consumer report on me/us and if the application is approved, you may at any time in the future obtain additional consumer reports to review my/our account. 'Ave have the right to ask for the name and address of the consumer reporting agency which gave the consumer report ' Cary Applicant Slgnatu % cois Joint Applicant Signature /1444-14....u.tA AVT1714, X 9 Certification By signing below, I certify under penalties of perjury that (1) The number shown on this form Is my correct taxpayer identification number; and (2) I am not subject to backup withholding because (a) 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 (b) 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). (J Check here if you are subject to backup withholding for failure to report Interest or dividends. [ Check here if you are not a U.S person (or a U.S. resident alien), and complete the appropriate Form W-8. ary4fApplIcant4SIg.Annature Joint Applicant Signature X •- eck Imaging or No ehecks With Statement: tilde authorize you not to return paid checks with my/our account statements. If I/we selected the Check Imaging option, I/we agree to receive images (front only) of my/our paid checks. I/We agree that the account statement will contain information about each check paid, including check number, dollar amount and date paid, thereby enabling a proper reconciliation of the account. Up,pp request, photocopies of checks will be provided. You will not retain original checks. Applicant jgnature Joint Applicant Signature Check here if v here are additonai sione on the reverse si X RANCH COPY. EFTA01481219  THE ABOVE INFCAMA Op AND (NO.) SIGNATURE(S) (PRIMARY AND IFAPPLICABLE) WERE VERIFIED BY: Print Name: i „- _5 Mats Dept. No.113( . No.: 7 Y3 BRANCH COPY-Retain card I b year after account doses. Then send to Pawling for additional retention of five years. POWER OF ATTORNEY INFORMATION DATE POWER OF ATTORNEY RECEIVED POWER OF ATTORNEY NAME POWER OF ATTORNEY SIGNATURE X ADDRESS (Street nd Number) CITY STATE ZIP CODE BENEFICIARY INFORMATION ADDITIONAL ACCOUNT SIGNERS - (For Estate and Trust oun , as needed)- Line out unused ign u boxes PRINT NAME TITLE SIGNATURE VERIFICATION Primary Applicant ID-1: DL ID#: M625620855610 St: FL Exp: 01/0112006 ID-2: PP D#: 4278011 St: Exp: 01/30/2013 ChexSystems:Approved Code:9500 SSN-ST:FL YR:2004 TU:Override CDE:B FPH: Override Approval By: 64.• Joint Applicant: D-1: ID : St: Exp: ID-2: ID#: St Exp: Chexsystems: Code: SSN-ST: YR: TU: CDE: FPH: NOTARY INFORMATION Worldwide o su Bank) STATE OF COUNTY OF SS.: On the day of before me personally came EFTA01481220 to me known, and known to me to be the individual described in, and who executed the foregoing instrument, and he acknowledged to me that he executed the same. THE ABOVE INFORMATION AND NO.) SIGNATURE(S) (POA AND ADDITIONAL SIGNERS) WERE VERIFIED BY: Pinl Name: initials Dept NoJBr. No.: 03-9415 (Stock Order #) FORM 113.DOC — 63 EFTA01481221