Liberty Bank Deposit Application

Checking and Savings Application

To apply for your account(s), please completely fill out the application, print it and visit your nearest location with your opening deposit and photocopies of your valid driver's license or stop in to see us at:

LIBERTY BANK
1002 North Main Street
Liberty, IL 62347

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

Account Information:

Type of Account	Deposit Amount
Checking Account: NOW Checking Account Personal Checking Account Banclub Checking Account Freedom 50 Checking Account Freedom 50 Plus Checking Account (min opening deposit of $100) (NOW Account min. deposit of $1,000)	$ ______________
Savings Account: Passbook Savings Account Golden Savings Account Christmas Club 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: 30 Days 91 Days 182 Days 12 Months IRA-12 Months 18 Months 24 Months 30 Months 36 Months 48 Months IRA-48 Months (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 visit your nearest location with your opening deposit and photocopy(s) of your valid driver's license or come see us at:

LIBERTY BANK
1002 North Main
Liberty, IL 62347

Barry Community
Banking Center
PO Box 132
Barry, IL 62312

Payson Community Banking Center
402 West State Street
Payson, IL 62360

Quincy Community
Banking Center
4134 Broadway Street
Quincy, IL 62305

Click to return to Liberty Bank Online!

Checking and Savings Application

Account Information:

Type of Account

Deposit Amount

Applicant Information

Applicant's Information

Co-Applicant's Information (If Applicable)

Applicant's Employment

Co-Applicant's Employment (If Applicable)

Check the box which applies:

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

Ensure the application is filled out correctly, print it and visit your nearest location with your opening deposit and photocopy(s) of your valid driver's license or come see us at: