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New Account Application

Important Information About Procedures for Opening a New Account:

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.

Opening Certificate of Deposit Account -

* Indicates Required Information

Account Holder Primary Owner Joint Owner
Name*
Business Name
D.O.B.* (MM/DD/YY) (MM/DD/YY)
SSN*
P.O. Box
Street Address
City*
State*
ZIP*
Driver's License Number*
Driver's License State*
Employer*
Email Address*
Home Phone* (000-000-0000) (000-000-0000)
Work Phone* (000-000-0000) (000-000-0000)
Place of Birth*
Mother's Maiden Name*

Ownership of Account

Personal Accounts
Single with POD Single without POD Multiple with ROS                                  
Multiple without ROS Multiple with ROS & POD
  List Beneficiaries
Commercial Accounts
Sole Proprietorship   Corporation Profit Corporation Non-Profit
Unincorporated Association Other Partnership

Account Setup Information

Initial Deposit
Previous Bank

Attachments

To further expedite your application, please attach a copy of your driver’s license and Secondary form of ID (e.g. Social Security, Voters Registration, Medical Ins Card, etc..)

If there are any other attachments that you feel would be beneficial, you may securely attach them here. If specific documents are required for processing your request, we will be in contact with you following our receipt of your application.  (Allowed file types include: doc, docx, pdf, zip, rtf, tif, jpg, and gif)

IMPORTANT: Maximum combined file size of 5MB
Internet Explorer users, you may receive an Active X warning when selecting files. This is our form checking the size of your upload files, and is normal. Please click Yes.

Certification

I certify that I am at least 18 years of age and I have accurately and fully completed all items on this application. Under penalties of perjury, I certify that:

  1. The social security number (SSN) and/or tax payer identification number (TIN) shown above is my correct number;
  2. I am NOT subject to backup withholding because (a) I am exempt from backup witholding, 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 Internal Revenue Service 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). 

Or check all that apply:

  I have been notified that I am subject to backup withholding.

  I am not a U.S. citizen or resident (complete W-8) form.

The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

Please note, this application is subject to verification and approval. In order for us to process your application correctly, we may need to contact you to verify some of the information or request additional documentation. When you submit this application, you certify that everything stated above is true and accurate. I understand and agree that if the institut ion is not able to verify the identity of all the owners of this account within a reasonable time, it may, at anytime, in its sole discretion, without providing advance notice, close the account.

If you have any questions, please contact us at (580) 562-4871, or by e-mail at info@washitastatebank.com.

By clicking below, I hereby certify that everything I have stated above is correct. You may keep this application whether or not it is approved. By clicking below, I understand that verification is done through Telecheck and OFAC.