UBM Direct Savings Account Application

Applicant

First Name *

Middle Initial

Last Name *

Email Address *

Primary Phone Number *

Primary Phone Type

Secondary Phone Number

Secondary Phone Type

Social Security Number *

Birth Date *

Identification (Driver's License or State Identification Information)

ID Number *

Issuer *

Issue Date *

Expiration Date *

Physical Address

Address *

City *

State *

Zip Code *

Length of time at current address Six Months or Greater Under Six Months

Mailing Address - if different than above

Address

City

State

Zip Code

Joint Applicant

First Name *

Middle Initial

Last Name *

Email Address *

Primary Phone Number *

Primary Phone Type

Secondary Phone Number

Secondary Phone Type

Social Security Number *

Birth Date *

Identification (Driver's License or State Identification Information)

ID Number *

Issuer *

Issue Date *

Expiration Date *

Physical Address

Address *

City *

State *

Zip Code *

Length of time at current address Six Months or Greater Under Six Months

Mailing Address - if different than above

Address

City

State

Zip Code

Initial Deposit Information

How will you fund this account?

Debit my checking account referenced above I will send a wire

Initial Deposit Amount *

Confirm Deposit Amount *

Would you like to enroll in the Automatic Savings Plan?

Yes No

I understand my account will be governed by the account terms and conditions in the account disclosure. By submitting this application, I agree to be bound by those terms and conditions. I also understand that I can close my account at any time and will receive all of my money in full, along with any interest owed to me, after any incurred fees or service charges. Under penalty of perjury, I certify that my Social Security Number on this application is my correct number. I am a U.S. person (including U.S. resident alien), and that (check the appropriate box): * I am not subject to backup withholding because I am exempt from backup withholding, or 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 I have been notified by the IRS that I am no longer subject to backup withholding. I am subject to backup withholding. (You must check this box if the IRS has notified you that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return.)

UBM Direct Savings Account Application