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Account Agreement
Institution Name & Address

Date:

Internal Use
Account Title & Address

Ownership of Account
IMPORTANT ACCOUNT OPENING INFORMATION: Federal law requires
us to obtain sufficient information to verify your identity. You may be
asked several questions and to provide one or more forms of
identification to fulfill this requirement. In some instances we may use
outside sources to confirm the information. The information you provide
is protected by our privacy policy and federal law.
Enter Non-Individual Owner Information on page 2. There is additional
Owner/Signer Information space on page 2.

Owner/Signer Information 1
Name
Relationship
Address

Mailing Address
(if different)

The specified ownership will remain the same for all accounts.
(For consumer accounts, select and initial.):
Uniform Single-Party or Multiple-Party Account Selection Form Notice:
The type of account you select may determine how property passes at
your death. Your Will may not control the disposition of funds held in
some of the following accounts:
l Single-Party Account with Payable-On-Death
(POD) Designation

l
l
l
l
l
l
l

Single-Party Account without POD Designation
Multiple-Party Account with Right of Survivorship
Multiple-Party Account with Right of Survivorship and POD
Multiple-Party Account without Right of Survivorship
Convenience Account
Trust Account (name beneficiaries below)

l
l
l
l
l

Home Phone
Work Phone
Mobile Phone
E-Mail
Birth Date

l
l

Corporation - For Profit
Partnership

Corporation - Nonprofit
Sole Proprietorship

Limited Liability Company
Trust-Separate Agreement Dated:

SSN/TIN

Beneficiary Name(s), Address(es), and SSN(s)

Gov't Issued Photo ID
(Type, Number, State,
Issue Date, Exp. Date)

(Check appropriate ownership above.)

Other ID
(Description, Details)
Employer
Previous
Financial Inst.

l

Owner/Signer Information 2
Name

The undersigned authorize the financial institution to investigate credit
and employment history and obtain reports from consumer reporting
agency(ies) on them as individuals. Except as otherwise provided by law
or other documents, each of the undersigned is authorized to make
withdrawals from the account(s), provided the required number of
signatures indicated above is satisfied. The undersigned personally and
as, or on behalf of, the account owner(s) agree to the terms of, and
acknowledge receipt of copy(ies) of, this document and the following:
l Terms and Conditions
l Privacy

Relationship
Address

Mailing Address
(if different)

l
l
l

Home Phone
Work Phone
Mobile Phone
E-Mail

Electronic Fund Transfers
Substitute Checks
Common Features

l
l
l

Truth in Savings
Funds Availability

Number of signatures required for withdrawal:
.
See Owner/Signer Information for Convenience Signer designation(s).

Birth Date
SSN/TIN
Gov't Issued Photo ID
(Type, Number, State,
Issue Date, Exp. Date)
Other ID
(Description, Details)

1 X

[

]

[

]

2 X

Employer

[

3 X

Previous
Financial Inst.

Signature Card-TX
Bankers Systems *
Wolters Kluwer Financial Services

If checked, this is a temporary account agreement.

Signature(s)

] [

4 X

]
MPMP-LAZ-TX 12/15/2006

-2003, 2006

Initials:

Page 1 of 2

Owner/Signer Information 3

Non-Individual Owner Information

Name

Name

Relationship

EIN
Phone

Address

Mobile Phone
E-Mail

Mailing Address
(if different)

Type of Entity

Home Phone

State/Country & Date
of Organization

Work Phone
Mobile Phone

Nature of
Business

E-Mail
Birth Date

Address

SSN/TIN
Gov't Issued Photo ID
(Type, Number, State,
Issue Date, Exp. Date)

Mailing Address
(if different)

Other ID
(Description, Details)

Authorization/
Resolution Date

Employer

Previous
Financial Inst.

Previous
Financial Inst.

Account Description Account #

Owner/Signer Information 4

Initial Deposit/Source

Name

$

Relationship

l
l

Address

Cash

l

Check

Cash

l

Check

Cash

l

Check

$

Mailing Address
(if different)

l
l

Home Phone
Work Phone
Mobile Phone

$

l
l

E-Mail
Birth Date
SSN/TIN

Services Requested

Gov't Issued Photo ID
(Type, Number, State,
Issue Date, Exp. Date)

l
l
l

Other ID
(Description, Details)

ATM

l

Debit/Check Cards (No. Requested:

)

l
l

Employer

Other Terms/Information

Previous
Financial Inst.

Backup Withholding Certifications
(If not a "U.S. Person," certify foreign status separately.)
TIN:

l

Taxpayer I.D. Number (TIN) - The number shown above is my
correct taxpayer identification number.
l Backup Withholding - 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.
l Exempt Recipients - I am an exempt recipient under the Internal
Revenue Service Regulations.

I certify under penalties of perjury the statements checked in
this section and that I am a U.S. person (including a U.S.
resident alien).
X

Signature Card-TX
Bankers Systems *
Wolters Kluwer Financial Services

(Date)

MPMP-LAZ-TX 12/15/2006

-2003, 2006

Initials:

Page 2 of 2