# Consumer Account Application

Bank Name:WELLS FARGO BANK, N.A.		Store Name:BELLEVIEW & KIPLING
Banker Name:BEEVERS, CHARLES		Officer/Portfolio Number:L6623	Date:11/17/2016
Banker Phone:	Store Number:06623	Banker AU:	Banker MAC:

To help the government fight the funding of terrorism and money laundering activities, U.S. Federal law requires financial institutions to obtain, verify, and record information that identifies each person (individuals and businesses) 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. # New Account Information **Product Name:** Wells Fargo Everyday Checking Account Number: Product: DDA **Purpose of Account:** Personal/Household Minor: 163 COID: **New Account Kit:** Checking/Savings Bonus Offer Available: NO ## Related Customers **Customer Name:** CARLOS PEREZ Account Relationship: Sole Owner ## Statement Mailing Information **Customer(s) Listed on Statement:** CARLOS PEREZ Statement Mailing Address: Address Line 2: City: State: ZIP/Postal Code: Country: US | DSG8921 | 5-16 SVP | | :--- | :--- | Page 1 of 2 2W02-000865833262-01 Wells Fargo Confidential EFTA00125032 Consumer Account Application Customer 1 Information

Customer Name: CARLOS PEREZ		Street Address:
Customer Number (ECN):		Address Line 2:
Account Relationship: Sole Owner		Address Line 3:
Taxpayer Identification Number (TIN): TIN Type: SSN Date of Birth:		City: State:
Primary ID Type:	Primary ID Description:	ZIP/Postal Code:	Country:	Time at this address:
Primary ID St/Cty/Prov:	Primary ID Issue Date: Primary ID Expiration Date:	US	4 Year(s)	10 Month(s)
Secondary ID Type: OTHER EM	Secondary ID Description: DEPARTMENT OF JUSTICE	Directional Address: (Document when no physical residence, business or alternate street address.)
Secondary ID State/Country: CO	Secondary ID Issue Date: Secondary ID Expiration Date: 03/31/2018
Home Phone:	Business Phone:	City:		State:
Current Employer: Butner Prison		ZIP/Postal Code:	Country:	Time at this address:
Check Reporting: NO RECORD				Year(s)	Month(s)

Customer Signatures Everything I have stated in this application is correct. You are authorized to make any inquiries that you consider appropriate to determine if you should open or maintain the account. This may include ordering a credit report or other report (i.e. information from any motor vehicle department or other state agency) on me. I have received a copy of the applicable account agreement and the privacy policy (each may be amended from time to time) and agree to be bound by their terms. I also agree to the terms of the dispute resolution program described in the foregoing agreements. Under the dispute resolution program, our disputes will be decided before one or more neutral persons in an arbitration proceeding and not by a jury trial or a trial before a judge. Customer 1 Name CARLOS PEREZ Customer 1 Signature Submit manually Signature not required Date: 11/17/2016 | DSG8921 | 5-16 SVP | | :--- | :--- | 2W02-000865833262-02 Page 2 of 2 Wells Fargo Confidential EFTA00125033