EFTA Document EFTA01279592

Consumer Account Application Bank Name: Store Name: 'WELLS FARGO BANK, N.A. THOMASVILLE MAIN WELLS FARGO Banker Name: OfficetePottlolio Number: Date [STEPHANIE T. VARNER 10/07/2014 Banker Phone: Store Number Bat AU: Banker MAC 110329 ;0067237 iD0133-010 To help the government fight the funding of terrorism and money laundering actvities,U.S. Federal taw requires financial institutions to obtain, verify, and record Infounadon that identifies each person (individuals and businesses) who opem an account What this means for you: When you open an account, we will ask for your name, addiess. date of birth and other information that will allowus to identify you. We may also ask to see your driver's license or other identifying documents. New Account Information Product Name IFMA Premier Checking Purpose of Account. IFersonal/Household 1338 Product Name: Aaount Hunter: (Wells Fargo High Yield Savings Purpose of Account Personal/Household 1338 Account Number: Minor (CAB Moor COW: flewAaouni Printed Related Customers Product: ,DDA Checking/Savings Bonus Offer Available: NO Newt: DDA Customer Name. Statement Mailing Information Account Relationship: Sole Owner Customer(s) I isted on Statement 0%8921 (5.14 SW:1 Statement Mailing Address. Address line City IIP/Pottal Code 2W02-000650149785-01 CONFIDENTIAL State COU try. Page 1 of 3 Wells Fargo Confidential SDNY_GM_00028591 EFTA_00139211 EFTA01279592 Consumer Account Application Customer 1 Information Customer Number (ECN): Account Relationship: (Sole Owner Taxpayer Identification Number (TIN) TIN Type: Date of Birth: ISSN Primary. Type: Primary ID Desorption. IDLIC PrimarylOSUCtry/Prov. Primary ID Issue Date: Primary. Expiration Date SecondaryIDType: Second ID Description: Street Address: Address Line Address line 3. Secondary . IDState/Country. Secondary ID Issue Date: Secondary IDExpiration Date. Home Phone: Business Phone. Current Employer. [Unemployed Check Reporting. NO RECORD City: State: ZIP/PostalCode Country. Treat thn address: Tear(s) Month(s) Directional Address' (Document alien no physical tesidence, business oraltemate meet address.) Previous Street Address: City /IP/PostalCode Country of Citizenship. US Request for Taxpayer Identification Number and Certification (Substitute form W.9) Under penalties of perjury. I certify that. 1 The number shown on this form is my correct taxpayer identification number for l am waiting for a number to be issued tome), and I UNLESS I HAW CHECKEDONEDE Itt BOAS 80.0%clern not subject to backup withholding either because I haw not been notified by the InWnal Revenue Service ORS) that l am subject to backup withholding as a result of a failure to report all interest or dividends, a the IRS has notified me that I am no longer subject to backup withholding (does not apply to real estate transactions, mortgage interest paid, the acquisrtiono abandonment of secured property, contributions to an Individual Retirement Arrangement (IRALand payment other than interest and dividends). 3 lama U.S. citizen or other U S. person. K I am subject to backup withholding I am exempt horn backup withholding 4.1 am exempt from Foreign Account Tax Compliance Act (FATCA) reporting. Country: State. Time at this address Yearrsi 'stand*) fax Resiinsible Customer Name: TINCenikation Signature tAIVOILltlair 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 applicabk account agreement and the privacy policy leach 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 dbpute 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. Ta a er bknbfdation Number am). Submit manually p Signature not required Due. 10/07/2014 DSG8921 (5-14 SVP) 2[402-000650149- 85-02 CONFIDENTIAL Page 2 of 3 Wells Fargo Confidential SDNY_GM_00028592 EFTA_00139212 EFTA01279593 Consumer Account Application Customer 1 Name Customer 1 Signature DSG8921 (5.14 SW) ▪ Submit manually K Signature not required 2W02-000650149785-03 Date: 10/07/2014 CONFIDENTIAL Page 3 of 3 Wells Fargo Confidential SDNY_GM_00028593 EFTA_00 I 39213 EFTA01279594