Cip Form - Retail Deposits/loans

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FOR OFFICE USE ONLY

Acct #(s):

Dep Amt(s):

Checking

Savings

SDB

Loans (Mortgage/Consumer)

CIP FORM – RETAIL DEPOSITS/LOANS

Important Information about Procedures for Opening a New Account

To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to

obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an

account, we will ask for your name, address, date of birth and other information that will allow us to identify you. We may also ask to see

your driver’s license or other identifying documents.

ACCOUNT OWNER / POA INFORMATION

Name

(First

Last)

Street Address

City

State/Country

Zip

Mailing Address (if different)

City

State/Country

Zip

(

)

(

)

Home Phone

Alternate Phone (e.g., business, cell, etc.)

E-mail Address

Identification Number

Date of Birth

Mother’s Maiden Name (Last name only)

(SSN/ITIN)

Employer Name

Job Title/Occupation

FOR OFFICE USE ONLY

ID Type/Verification Documents:

Driver’s License

State ID

US Military/Gov’t ID

Credit Card

Utility Bill

Bus Pass

Other _________________

Student ID (Restricted to persons 17 or under with Social Security Card)

Passport (If US Passport, provide a secondary/alternative ID (required). Refer to list of Secondary and Alternative IDs in Br Procedure #1300D-03.01PROC.)

Credit Report (Loans Only)

Resident Alien Card (Loans Only) *photocopy required

Other _________________ (Contact BSA/AML Officer or BSA/AML Specialist Supervisor) Approved by: ______________________

Issuing State/Country

ID Number

Issue Date

Expire Date

CUSTOMER INFORMATION DISCREPANCIES

Note any differences between the information provided in the Account Owner Information section and the ID presented. Document the steps taken to

resolve the differences (i.e., What steps were taken to ensure the identity of the customer? For example, customer provided a utility bill, letter mailed to

customer at address written in Account Owner / POA Information section, etc.).

Type of Discrepancy:

ID Number

Name

Address

DOB

Steps taken to resolve/Additional Information::

Rev. 10/1/2014