□ Checking
□ Individual
New Account Application
□ Savings
□ Joint Account □ Beneficiary □ OFAC
□ CIP
Name
Address
_______________________
Personal Banker
SS#
City, State, ZIP
Employer
DOB
Home Phone
Work Phone
Length with current employer (yrs/mo) _____________________ Identification __________
DL#_________________ Issue Date _____________ Ex Date _____________ State ______
(Joint owner) Name
Address
SS#
City, State, ZIP
Employer
DOB
Home Phone
Work Phone
Length with current employer (yrs/mo) _____________________ Identification __________
DL#_________________ Issue Date _____________ Ex Date _____________ State ______
Direct Deposit
Employer/Payer ____________________________________________________
Address ___________________________________________________________
Phone ______________________ Account # ____________________________
Name ___________________________________ Date ____________________
Signature __________________________________________________________
I have moved my account to Gothenburg State Bank. Please consider this request, indicated by my
original signature, as a formal order to forward my pending or future deposits to my new account
with Gothenburg State Bank, 900 Lake Ave, Gothenburg, NE 69138.
Routing Number: 104901607
New Account Number: _______________
□ Checking □ Savings
Automatic Payment
Payee _____________________________________________________________
Address ___________________________________________________________
Phone ______________________ Account # ____________________________
Name ___________________________________ Date ____________________
Signature __________________________________________________________
I have moved my account to Gothenburg State Bank. Please consider this request, indicated by my
original signature, as a formal order to forward my pending or future withdrawals from my new
account with Gothenburg State Bank, 900 Lake Ave, Gothenburg, NE 69138.
Routing Number: 104901607
New Account Number: _______________
□ Checking □ Savings
Automatic Payment
Payee _____________________________________________________________
Address ___________________________________________________________
Phone ______________________ Account # ____________________________
Name ___________________________________ Date ____________________
Signature __________________________________________________________
I have moved my account to Gothenburg State Bank. Please consider this request, indicated by my
original signature, as a formal order to forward my pending or future withdrawals from my new
account with Gothenburg State Bank, 900 Lake
Ave, Gothenburg, NE 69138.
Routing Number: 104901607
New Account Number: _______________
□ Checking □ Savings
Financial Funds Transfer Request
1. Customer Information
Account Owner_______________________________________ SS#________________________________
Co-Owner___________________________________________________________ SS#________________________________
Address___________________________________ City____________________________ State________ Zip______________
2.
Transfer My Account FROM:
Financial Institution______________________________________ Account #__________________
Please transfer $__________________
Please send a check to:
My address listed above
Please transfer the entire amount and
close my account.
Gothenburg State Bank
PO Box 81, Gothenburg, NE 69138
(Please make the check payable to Gothenburg State Bank for
benefit of _________________________ Acct#_______________)
I hereby direct you to complete the requested transfer from my existing account to my new account at Gothenburg State Bank.
If you have any questions about this request, please contact me at ___________________________(phone number).
Customer’s Signature___________________________________________________ Date______________________________
Co-Owner’s Signature___________________________________________________ Date_____________________________
*This form is not needed if you are writing a check*
Automatic Payment
Payee _____________________________________________________________
Address ___________________________________________________________
Phone ______________________ Account # ____________________________
Name ___________________________________ Date ____________________
Signature __________________________________________________________
I have moved my account to Gothenburg State Bank. Please consider this request, indicated by my
original signature, as a formal order to forward my pending or future withdrawals from my new
account with Gothenburg State Bank, 900 Lake Ave, Gothenburg, NE 69138.
Routing Number: 104901607
New Account Number: _______________
□ Checking □ Savings