TERM AND DEPOSIT AMOUNT:

___ Please open a 9 Month Passbook CD for $ _____________ ($1,000 Minimum Opening Deposit) at a 1.75% APY* (offer subject to change daily).

ACCOUNT TITLE REQUESTED (select one):

___ INDIVIDUAL account (Complete Name 1 - One Account Owner)
      [To add a BENEFICIARY, complete Name 3  - Make it an "In Trust For" Account]
OR
___ JOINT account (Complete Names 1 & 2 - Two Account Owners)
      [To add a BENEFICIARY, complete Name 3 - Make it an "In Trust For" Account]
OR
___ CUSTODIAL account (Under the CT Uniform Transfer To Minor's Act - CT UTMA) 
      [List the Minor in Name 1 & the Custodian in Name 2]

NAME 1:

___________________________________________________________
Primary Account Owner (Or Minor if custodial)

Social Security #: ________ /______/__________ Date of Birth ____/____/______
(To be used for tax reporting purposes)

Home Address : ________________________________________________________

City, State, Zip: _________________________________________________________

Home Phone: (______)_______-_________ Work Phone: (______)_______-_________

Relationship of Minor to Custodian (If custodial account): ______________________________

NAME 2:

______________________________________________________________
Joint Account Owner (Or Custodian)

Social Security #: ________ /______/__________ Date of Birth ____/____/______

Home Address : _________________________________________________________

City, State, Zip: __________________________________________________________

Home Phone: (______)_______-_________ Work Phone: (______)_______-_________

NAME 3 (FOR BENEFICIARY USE ONLY):

______________________________________________________________
Beneficiary's Name (IN TRUST FOR accounts only)

Beneficiary's Social Security #: ________ /_______/__________ Date of Birth ____/____/______

Home Address : ________________________________________________________

City, State, Zip: _________________________________________________________

Home Phone: (______)_______-_________ Work Phone: (______)_______-_________

Relationship of Beneficiary to Account Owner(s): __________________________________________

ACCOUNT MAILING ADDRESS (If other than the HOME address for Name 1):

Account Mailing Address : ___________________________________________________

City, State, Zip: ____________________________________________________________

AUTHORIZED SIGNATURE(s): (Required) 

___________________________________________________________ Date __________
Primary Account Owner

___________________________________________________________ Date __________
Joint Account Owner or Custodian

PLEASE SIGN BELOW TO CERTIFY YOUR SOCIAL SECURITY NUMBER:  (Required) 

Certification of Taxpayer Identification Number (TIN) 
Under penalties of perjury, I certify that (1) the number shown on this form is my correct taxpayer identification number and (2) (a) I am not subject to backup withholding for the reason checked below, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and (3) I am a U.S. person (including a U.S. resident alien). You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return.

___________________________________________________________ Date __________
Primary Account Owner or Custodian

I am exempt from backup withholding because I am a(n): (circle one)

• Exempt Payee (Form W-9 required)
• Non-Resident Alien (Form W-8 required)

* Minimum deposit of $1,000 required to open Passbook account and earn Annual Percentage Yield (APY).This offer may be withdrawn without notice. Substantial penalty for early withdrawal. Fees may reduce earnings on the account. Rate is subject to change daily. Maximum deposit is $250,000 per customer.    

(FOR BANK USE ONLY) ACCOUNT No:___________________________________