EFTA00124347¶
| Account Number : 613055768 Checking -Signature Card | 1 |
| Account Number : 2741208041 Savings -Signature Card | 2 |
| Account Number : 00000000000613055768 Statement and/or items | 3 |
EFTA00124348¶
CHASE¶
ACCOUNT NUMBER¶
Chase Total Checking¶
PERSONAL ADDRESS¶
| DATE OPENED | 07/16/2014 |¶
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| ISSUED BY | JPMorgan Chase Bank, N.A. (802) |¶
| :--- | :--- |¶
NEW YORK, NY 10039-3517¶
United States/US Territories¶
TYPE OF OWNERSHIP Individual¶
| TAXPAYER ID | DATE OF BIRTH | PRIMARY ID TYPE | PRIMARY ID NUMBER | ISSUER NY | ISSUANCE DATE | EXP DATE | SECONDARY ID TYPE | SECONDARY ID NUMBER | ISSUER HUMC | ISSUANCE DATE | EXP DATE |
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| 1 | State Issued ID | Employer ID | 08/01/2014 | ||||||||
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CUSTOMER(Si TO BE ADDED LATER)¶
KNOWLEDGEGEMENT - By signing this Signature Card, I am applying to the JPMorgan Chase Bank, N.A. (The Bank) to open the deposit account and/or Chase LiquidB indicated above. I certify that the information provided herein is true to the best of my knowledge and authorise the Bank, on its discretion, to obtain credit reports and employment verifications on me. I acknowledge receipt of the Bank’s Deposit Account Agreement or other applicable account agreement or this Chase Liquid Terms and Conditions, which includes all provisions that apply to this deposit account and/or Chase Liquid Card and the Bank Privacy Policy, and agree to be bound by the terms and conditions contained therein as amended from time to time. For joint accounts, I agree that all parties are responsible for any overdraft of any amount due to the return of a deposited check without condition or limitation.¶
[___] According to the IRS Form W-4 instructions, if you are only submitting this form for an account you hold in the United States, you may have field blanks.¶
CERTIFICATION I certify under penalties of perjury that (1) the Taxpayer Identification Number shown above is correct, and (2) I am not subject to backup withholding because: (a) I am not from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of failure to report all internet or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and (3) I am a U.S. citizen or other U.S. person (as defined in the Form W-8 Instruction), and (4) the FATCA code) entered on this form (if any) indicating that I are exempt from FATCA reporting is correct.¶
If the IRS has notified you that you are subject to backup withholding due to underreporting interest or dividends on your tax return, cross out item 2 above.¶
Narma¶
17 ROBERT C. ADAMS¶
Telephone Number¶
- Tax Responsibility Indicator
Rev 2014¶
SB1063781-F1¶
Page 1 of 1¶
1¶
EFTA00124349¶
CHASE¶
Consumer Signature Card¶
ACCOUNT NUMBER 2741258041¶
ACCOUNT TYPE Chase Savings¶
TAX RESPONSIBLE ID #¶
CONSUMER ADDRESS¶
NEW YORK, NY 100393517¶
CUSTOMER(S) TO BE ADDED LATER¶
ACKNOWLEDGEMENT¶
By signing this Signature Card, I am applying to a PJ Morgan Chase Bank, N.A. (the Bank) to open the deposit account indicated above. I certify that the information provided herein is true to the best of my knowledge and authorize the Bank, at its discretion, to obtain credit reports and employment verifications on me. I acknowledge receipt of the Bank’s Accounts Rules and Regulations or other applicable account agreement, which includes all provisions that apply to this deposit account and the Bank Privacy Policy and agree to be bound by the terms and conditions contained therein as amended from time to time. For joint accounts, I agree that all parties are responsible for any overdraft of any amount due to the issuer of a depleted check without condition or limitation.¶
CERTIFICATION I identify under penalties of perjury that (1) the Taxpayer Identification Number shown above is correct, 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 as a result of failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and (d) I am a U.S. person (including a U.S. resident alien).¶
- If the IRS has notified you that you are subject to backup withholding due to underreporting interest or dividends on your tax return, cross out item 2 above.*
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.¶
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SB1063781-F1¶
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