The Farmers Bank of Liberty

 

Checking and Savings Application

To apply for your account(s), please completely fill out the application, print it and mail it with your opening deposit and photocopies of your valid driver's license to:

The FARMERS BANK of Liberty
1002 North Main Street
Liberty, IL 62347

Upon approval of your application and receipt of your opening deposit, FBL will open the account(s) requested and send you a receipt and other important information about your account(s). Accounts opened will be subject to the FARMERS BANK of Liberty's rates, fees and balance requirements. If you have any questions regarding this application, please call (217) 645-3434 and ask for Customer Service, or e-mail us.

 

Account Information:

Type of Account

Deposit Amount

Checking Account:

(min opening deposit of $100)
(NOW Account min. deposit of $1,000)

$

Savings Account:


(min opening deposit of $10)
(Golden Savings Account min opening deposit of $500)

$

Insured Money Fund (IMF) Account:

Click Here to Select this Account
(min opening deposit of $2,500)

$

Certificate of Deposit Account:


(min. opening deposit of $1,000 less than 12 mos.
min opening deposit of $500 12 mos. and greater)

$

 

Applicant Information:

Applicant's Information:

Co-Applicant's Information: (If Applicable)

First Name

First Name

MI

MI

Last Name

Last Name

Home Phone ( ) -

Home Phone ( ) -

Marital Status

Married
Separated
Unmarried

Marital Status

Married
Separated
Unmarried

Date of Birth / /

Date of Birth / /

Social Security Number - -
(or Federal Employer Identification Number, if applicable, for Business Accounts)
TIN -

Social Security Number - -
(or Federal Employer Identification Number, if applicable, for Business Accounts)
TIN -

Driver's License Number
- - State

Driver's License Number
- - State

Address
City
State ZIP -

Address
City
State ZIP -

Own
Rent

No of years:

Own
Rent

No of years:

E-mail:

E-mail:


Applicant's Employment

Co-Applicant's Employment (If Applicable)

Check if self-employed

Check if self-employed

Name of Employer

Name of Employer

Address


Address

City

City

State

State

ZIP -

ZIP -

Phone ( ) -

Phone ( ) -

Type of Business

Type of Business

Position/Title

Position/Title

Years at employer

Years at employer

Years in profession

Years in profession

 

Under penalties of perjury, the undersigned certifies that: 1) the number on this form is my correct taxpayer identification number: (TIN) and 2) I am not subject to backup withholding because one of the following applies: 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 the IRS has notified me that I am no longer subject to backup withholding. You must cross out item( 2) above if you have been notified by the IRS that you are currently subject to backup withholding.

Check the box which applies:

Foreign Recipient: I certify that I am neither a resident nor a U.S. citizen and therefore, I am not subject to backup withholding. Also, I've provided my permanent address to the bank.

Applied for TIN: I certify that a TIN has not been issued to me and that I have applied or intend to apply for a TIN. I understand that this account is subject to immediate withholding of 31% of any payments made to me until I provide a certified TIN to the bank. I further understand that if no TIN is provided within 60 days, the Bank has a right to close this account and deliver the proceeds to me, less any penalties and less any amounts withheld pursuant to this provision.

The certifications above do not apply to all signers. Individual certifications have been provided by all account owners.

The Internal Revenue Service does not require your consent to any provisions of this document other than the certifications required to avoid backup withholding.

 

Applicant
Signature

 
 


Applicant TIN
(Social Security Number/
Tax ID Number)

 
 


Joint Applicant
Signature

 
 


Joint Applicant TIN
(Social Security Number/
Tax ID Number)

 

ACCOUNT AGREEMENT: Everything that is stated in this new account application is correct to the best of my (our) knowledge. I (We) give this information for the purpose of obtaining the type of account(s) stated on this application. I (We) authorize the Bank to obtain information concerning any statements made here; to answer any questions about its credit experience with me (us); and to share any information obtained concerning or contained in this application with third parties; including credit reporting agencies. I (We) understand that a credit report may be requested in connection with this application.

I (We) authorize the sharing of this application, any information relating to the account(s) opened and any information obtained concerning this application with any of the Bank's affiliates.

JOINT WITH RIGHT OF SURVIVORSHIP AGREEMENT (if more than one signature): We intend to and do hereby create a joint account with rights of survivorship.

I (We) understand and agree that when the Bank opens the account(s) requested, I (We) will be bound by the terms and conditions governing the accounts as they may be amended from time to time.

 
 

Applicant if UGMA account (or custodian)

Date

 
 

Joint Applicant

Date


Ensure the application is filled out correctly, print it and sign it, and mail it with your opening deposit and photocopy(s) of your valid driver's license to:

The Farmers Bank of Liberty
Click to return to FBL Online!

The FARMERS BANK of Liberty
1002 North Main Street
Liberty, IL 62347