Personal Customer Identification Form - Community National Bank

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 and account. What this means for you: When you open an account, we will ask you 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.

Account Owner: Authorized Signer (addit'l information required, Section I) Includes: Custodians, Guardians, Rep Payee, Executor, Trustee, Auth Signers on Business Accounts

Section I - Personal Information

Name*

DBA Name

if applicable

SSN*

DOB

EIN

if applicable

if Authorized Signer, provide Account holder Name

Account #

Physical Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Alt Phone

Email Address*

OCCUPATION*

DL/ID#

Issue Date

State

Exp Date

Section II - Identification (*required)

U.S. Citizen?*

Yes
No

(*must complete W-8 and Due Diligence)*

W-8

Primary

State DL/ID
Passport
US Alien Reg
Military ID

No.

Exp.

Secondary

Social Security
Medicare Card
Birth Certificate
Voter Reg Card
Firearms Lic

Address Verification

Propery Tax Bill
Utility Bill
Insurance Card
Other

Other

Sole Proprietorship (DBA)

Select

EIN (if applicable)
Assumed Name Certificate
Resolution
SB Form

Fiduciary/Trust

Select

Trust Agreement Revocable
Living Trust SSN Irrevocable
Formal Trust TIN

Minor - TXUTMA

Select

Birth Certificate (photocopy)
SS Card (photocopy)
OFAC (JH)

Estate Account

Select

Letters Testamentary
EIN