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� HIC?CdRY POINT BANK & TRUST, fsb ACCOUNT PORTFOLJO <br /> 1401 W HICKORY POINT DRIVE NUMBER 29939 NUMBER 179073 <br /> FORSYTH, IL 62535 <br /> ' ACCOUNT OWNER(S)NAME&ADDRESS <br /> HICKORY POINT DEMIRCO PLACE CITY OF DECATUR <br /> FLEX PLAN <br /> OWNERSHIP OF ACCOUNT -CONSUMER PURPOSE <br /> ❑ INDIVIDUAL ❑ <br /> ❑ JOINT-WITH SURVIVORSHIP(and not as tenants in common) <br /> ❑ JOINT-NO SURVIVORSHIP(as tenants in common) <br /> ❑ TRUST-SEPARATE AGREBv1ENT: PO BOX 10 68 <br /> DECATUR IL 62525 - <br /> ❑ REVOCABLE TRUST OR ❑ PAY-ON-DEATH � <br /> DESIGNATION AS DEFINm IN THIS AGREIIv1ENT <br /> Name and Address of Beneficiaries: <br /> � � NEW ❑ DCISTING <br /> TYPE OF � CHECKING ❑ SAVINGS <br /> ACCOUNT � MONEY MARKET ❑ CERTIFICATE OF D�OSIT <br /> • ❑ NOW ❑ 7001214 <br /> This is your(check one):POINT COMMERCIAL <br /> ❑ Permanent ❑ Temporary account agreement. <br /> Point Commer'Cial Corp ( NOn Prof it) Number of signatures required for withdrawal One <br /> FACSIMILESIGNATURE(S) ALLOWm? ❑ YES � NO <br /> OW NERSHIP OF ACCOUNT-BUSINESS PURPOSE <br /> ❑ SOLE PROPWEfORSHIP <br /> ❑ CORPORATION: ❑ FOR PROFIT ❑ NOT FOR PROFIT X <br /> ❑ PAFzfrvERSHIP SIGNATURE(S) -The undersigned agree to the terms stated on every <br /> � PUBLIC FUNDS—MLTNICIPAL page of this form and acknowledge receipt of a completed copy. The <br /> undersigned further authorize the financial institution to verify credit <br /> BUStNESS: �ITY OF DECATUR and employment history and/or have a credit reporting agency <br /> COUNTY& STATE prepare a credit report on the undersigned, as individuals. The <br /> OF OrtGArviZ.4TtOrv: undersigned also acknowledge the receipt of a copy and agree to the <br /> a,UTHOwZaTioN Da,Tm: terms of the following disclosure(s): <br /> � Deposit Account � Funds Availability � Privacy <br /> �ArE oPElvm 12/0 8/2 0 0 3 BYK COMSTOCK � eectronic Funds Transfer ❑ Truth in Savings <br /> INITIAL DEPOSIT$ ❑ <br /> ❑ CASH ❑ CHECK ❑ <br /> HOMET��HONE# (1>' X � � ��� � /���� <br /> BUSINESS PHONE# ` <br /> DWVER'S LICENSE# CITY OF DECATUR <br /> E-MAIL I.D.# 37-6001308 D.O.e. <br /> Hv1PLOYH� � � /�/� <br /> MOTHER'S MAIDEN NAME C <br /> �2): <br /> Name and address of someone who will always know your location: _ X � <br /> DANNY R REYNOLDS SR <br /> I.D.# D.O.e. <br /> BACKUP WITHHOLDING CERTIFICATIONS <br /> TIN: 37-6001308 �3�' X <br /> � TAXPAYER I.D. NUMBER • The Taxpayer ldentification • <br /> Number shown above (TIN) is my correct taxpayer identification I.D.# D.o.e. <br /> number. <br /> � BACKUP WITHHOLDING - I am not subject to backup <br /> withholding either because I have not been notified that I am �4)' X <br /> subject to backup withholding as a result of a failure to report all <br /> interest or dividends, or the Internal Revenue Service has notified � <br /> me that I am no longer subject to backup withholding. I.D.# D.O.B. <br /> ❑ IXEMPT RECIPIENTS - I am an exempt recipient under the <br /> Internal Revenue Service Regulations. ❑authorized signer(Individual Accounts Oniy) <br /> SIGNATURE: I certify under penalties af perjury the statements checked in this <br /> saction and that I am a U.S.person lincluding a U.S.resident alien►. <br /> x <br /> ��C'-�--� '�`� . C a-.,�-�2�-- x <br /> CITY OF DECATUR (Date) I.D.# D.o.B. <br /> ���o Q992 Bankers Systems,Inc.,St. Goud,MN Form MPSGLAZ-IL 11/21/2000 (page 1 of 2) <br />