www.bankheritage.com

PERSONAL ACCOUNT APPLICATION

ACCOUNT TYPE:

(___) Checking (___) Super NOW (___) Savings (___) Minor Savings (___) e-Statements

(___) Money Market (___) CD (___) IRA (___) Safe Deposit Box (___) Visa Debit Card

Applicant #1 / Applicant #2
Physical Address
(Required) / Physical Address
(Required)
City, State, Zip / City, State, Zip
Social Security # / Social Security #
Driver’s License # / Driver’s License #
Issued By / Issued By
Exp. Date / Exp. Date
Date of Birth / Date of Birth
Home Phone / Home Phone
Cell Phone / Cell Phone
Work Phone / Work Phone
Employer / Employer
Occupation / Occupation
Email Address / Email Address
Mailing Address (if different)
City / State / Zip / Country
Beneficiary 1: / Relationship: / DOB:
Beneficiary 2: / Relationship: / DOB:

US Citizen: (___) Yes (___) No Resident alien: (___) Yes (___) No

Existing Customer: (___) Yes (___) No Referred by: ______Former Financial Institution: ______

IMPORTANT INFORMATION ABOUNT 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 that 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.

To help us determine which services are right for you, please answer the following questions about how you will be using your new account.

Purpose of the account: ______

What is the source of funds used to open this account? ______

What type items do you expect to be deposited to the account?

___ Cash ___ Checks ___ Direct Deposit ___ ACH ___ Wire Transfer

How frequently will deposits be made? ______

Estimate the amount of deposits $______

Estimate the average balance $______

What methods do you expect to use to remove funds from the account?

___ Checks ___ ATM ___ Debit Card ___ Automated Bill Pay ___ Wire Transfer

Do you anticipate receiving funds from outside the US or sending funds outside the US? ______

Are you or any of your relatives or associates connected to the government of a country other than the US? ______

Customer Certification and Authorization

I certify that the above information is true and complete, and authorize you to verify the above information and to obtain further information concerning my credit history and standing and deposit accounts maintained with other institutions. Under the penalties of perjury, I certify (1) the social security number shown above next to my name is my correct taxpayer identification number, and (2) I am not subject to backup withholding either because 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 because the IRS has notified me that I am no longer subject to backup withholding. (Instructions to Applicant(s): If you have been notified by the IRS that you are currently subject to backup withholding because of underreporting interest or dividends on your tax return and you have been notified that the backup withholding has terminated, you must strike out the language in clause (2) above.

______

Signature Date Signature Date

DEBIT CARD APPLICATION

I authorize Heritage Bank to verify the information contained on this application and to obtain further information from a consumer credit report to assist in the review process. When I, or someone authorized, use this account, I agree to the terms and conditions of the agreement that governs the use of Heritage Bank Visa Cash Card. I will receive a copy of the agreement when I receive my card. I understand that if my checking account becomes overdrawn due to a Cash Card transaction, an overdraft fee will be charged.

______

Signature Date Signature Date

FOR BANK USE ONLY

DATE OPENED: ______ACCOUNT #______ACCOUNT TYPE: ______

BRANCH: ______RESP. CODE: ______RISK RANKING: ______

Initial Deposit: $______Source of Funds: ______HOLD PLACED: ______/ ______

Amt. of Hold # of days

Opened by: ______Date: ______CD TERM: ______

(__) Check Order (__) Debit Card Application (if applicable) INTEREST: (__) Compound (__) Credit Account #: ______

Revised 1/7/2015Page 1