Patriot Act Information Disclosure Page 4
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4Customer Identification Documentation
Patriot Act
The USA Patriot Act requires all financial institutions to obtain, verify and record information that identifies every customer.
Completion of this documentation is required in order to comply with the USA Patriot Act. A completed copy of this
information must be retained with the loan file.
Application Number
Date
Name of Applicant
Social Security #
Date of Birth
Present Address
Mailing Address
Primary Identification Documentation
Document Type
Other Document Type
Document Number
Issue Date
Expiration Date
Issued by
Secondary Identification Documentation
Document Type
Other Document Type
Document Number
Issue Date
Expiration Date
Issued by
Discrepancies and Resolution
Completed by
Calyx Form (4/04)
BRWIDDoc.frm
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