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Ownership

  Single Owner (individual)
  Joint (right to survivorship)
  Joint (no right to survivorship)
  Payable on Death (POD)

Account Type


Primary Account Owner

*Name (First M. Last)
*Date of Birth (mm/dd/yyyy)
*Social Security Number:
*Address
*City, State Zip ,
*Home Phone Number ( ) -
*Work Phone Number ( ) -
*Driver's License Number   *State
*E-mail



Secondary Account Owner

(if you selected secondary account ownership)

Name (First M. Last)
Date of Birth (mm/dd/yyyy)
Social Security Number
Driver's License Number   State



Payable on Death Beneficiary

(if you selected POD ownership)

Name (First M. Last)
Social Security Number
Phone Number ( ) -
Address
City, State Zip ,



Deposit Information


*Initial Deposit $
*Initial Deposit Type



Taxpayer Identification Number Certification


The Social Security Number(s) shown above is my correct SSN.

I am not subject to backup withholding either because I have not been notified that I am subject to backup withholding as a result of a failure to report all interest or dividends, or the Internal Revenue Service has notified me that I am no longer subject to backup withholding.

I am an exempt recipient under the Internal Revenue Service Regulations.

I am not a United States person, or if I am an individual, I am neither a citizen nor a resident of the United States.

I certify under penalties of perjury the statements checked in this section are true.

I would like to access this account through Online Banking.



I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand and agree that completing this form does not obligate Franklin Bank to open the account.


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