Deposit Application

* indicates a required field

Once we receive your account application we will review it and make contact with you to complete documentation. If you are a first time customer, you will be required to come into a branch to sign documentation.

Ownership

*Is this an individual or joint application?

Single Owner (individual)
Joint (right to survivorship)

Primary Account Owner

*Name (First M. Last)	First Name Middle Initial Last Name
*Date of Birth (mm/dd/yyyy)
*SSN
*Mailing Address
*City, State Zip-Plus4	,
Physical Address (If different from Mailing Address)
Physical City, State Zip	,
*Home Phone Number
*Work Phone Number
*Best Phone Number to Reach You
*Employer:
*Driver's License Number	State
*Issue Date (mm/dd/yyyy)
*Expiration Date (mm/dd/yyyy)
*Email
*Mother's Maiden Name
*Birthplace City
*Occupation
	I am a citizen of the U.S.

Joint Account Owner

(if you selected joint account ownership)

Name (First M. Last)	Joint Owner 1: First Name Joint Owner 1: Middle Initial Joint Owner 1: Last Name
Date of Birth (mm/dd/yyyy)
SSN
Mailing Address:
City, State Zip	,
Physical Address (If different from Mailing Address)
Physical City, State Zip	,
Home Phone Number
Work Phone Number
Employer:
Driver's License Number	State
Issue Date (mm/dd/yyyy)
Expiration Date (mm/dd/yyyy)
Email
Mother's Maiden Name
Birthplace City
Occupation
	I am a Citizen of the U.S.

Name (First M. Last)	Joint Owner 2: First Name Joint Owner 2: Middle Initial Joint Owner 2: Last Name
Date of Birth (mm/dd/yyyy)
SSN
Mailing Address:
City, State Zip	,
Physical Address (If different from Mailing Address)
Physical City, State Zip	,
Home Phone Number
Work Phone Number
Employer:
Driver's License Number	State
Issue Date (mm/dd/yyyy)
Expiration Date (mm/dd/yyyy)
Email
Mother's Maiden Name
Birthplace City
Occupation
	I am a Citizen of the U.S.

Name (First M. Last)	Joint Owner 3: First Name Joint Owner 3: Middle Initial Joint Owner 3: Last Name
Date of Birth (mm/dd/yyyy)
SSN
Mailing Address:
City, State Zip	,
Physical Address (If different from Mailing Address)
Physical City, State Zip	,
Home Phone Number
Work Phone Number
Employer:
Driver's License Number	State
Issue Date (mm/dd/yyyy)
Expiration Date (mm/dd/yyyy)
Email
Mother's Maiden Name
Birthplace City
Occupation
	I am a Citizen of the U.S.

Name (First M. Last)	Joint Owner 4: First Name Joint Owner 4: Middle Initial Joint Owner 4: Last Name
Date of Birth (mm/dd/yyyy)
SSN
Mailing Address:
City, State Zip	,
Physical Address (If different from Mailing Address)
Physical City, State Zip	,
Home Phone Number
Work Phone Number
Employer:
Driver's License Number	State
Issue Date (mm/dd/yyyy)
Expiration Date (mm/dd/yyyy)
Email
Mother's Maiden Name
Birthplace City
Occupation
	I am a Citizen of the U.S.

Payable on Death Beneficiary

Would you like a beneficiary on this account. If yes who?

Name (First M. Last)	Beneficiary 1: First Name Beneficiary 1: Middle Initial Beneficiary 1: Last Name
SSN
Date of Birth
Phone Number
Address
City, State Zip-Plus4	,

Name (First M. Last)	Beneficiary 2: First Name Beneficiary 2: Middle Initial Beneficiary 2: Last Name
SSN
Date of Birth
Phone Number
Address
City, State Zip-Plus4	,

Name (First M. Last)	Beneficiary 3: First Name Beneficiary 3: Middle Initial Beneficiary 3: Last Name
SSN
Date of Birth
Phone Number
Address
City, State Zip-Plus4	,

Name (First M. Last)	Beneficiary 4: First Name Beneficiary 4: Middle Initial Beneficiary 4: Last Name
SSN
Date of Birth
Phone Number
Address
City, State Zip-Plus4	,

Deposit Information

Initial Deposit	(Do not use commas or dollar signs)
*Where will funds be deposited from?

*Branch Location

I (We) would also wish to apply for the following accounts: I wish to add the following features to my account:
VISA Debit Card
VISA Debit Cards for All Owners
ATM Card
ATM Cards for All Owners
Overdraft Protection - Ready Reserve LOC - Upon Credit Approval - Additional Credit Application to be Completed.

Taxpayer Identification Number Certification

*Social Security Number(s) The Social Security Number(s) shown above is my correct SSN.

*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.

Exempt Recipients I am an exempt recipient under the Internal Revenue Service Regulations.

Nonresident Alien. I am not a United States person, or if I am an individual, I am neither a citizen nor a resident of the United States.

*I certify under penalties of perjury the statements checked in this section are true.

I (We) agree that the use of any Debit Card ("Card") issued in response to this application will constitute my (our) agreement to be jointly and severely bound by the terms and conditions of the Debit Card Agreement delivered with your new account disclosures. It is certified that the above information is complete and true, and is given to induce you to issue said Card(s). I (We) authorize you to make whatever credit and/or investigative inquires deemed necessary in connection with this application. I (we) will contact a personal banker to select a Personal Identification Number (PIN). I (We) understand that this Card is not a Credit Card, and that no commitment to extend credit to me (us) will be made by your issuance of the Debit Card(s) requested.

*I (We) acknowledge and agree to the terms and conditions as outlined above.

Please order one box of blue safety checks with the account owner name(s), phone number and address. If you wish to change the check design, please contact Customer Service by e-mail or call us at 620-241-7404.

*I authorize Citizens State Bank to obtain a copy of my current credit report as a condition of acceptance of this application and for the purpose of extension of or renewal of credit.

I would like to access this account through Online Banking. (Additional Online Banking Registration will be required for each user.)

IF YOU CANNOT PRINT WEB DOCUMENTS, CHECK HERE

*Everything I have stated in this application is correct to the best of my knowledge.

* indicates a required field