Sec. 113.052. FORM.
A financial institution may use the following form to establish the
type of account selected by a party: (1233)
UNIFORM SINGLE-PARTY OR MULTIPLE-PARTY ACCOUNT
SELECTION FORM NOTICE: The type of account you select may
determine how property passes on your death. Your will may not
control the disposition of funds held in some of the following
accounts. You may choose to designate one or more convenience
signers on an account, even if the account is not a convenience
account. A designated convenience signer may make transactions
on your behalf during your lifetime, but does not own the account
during your lifetime. The designated convenience signer owns the
account on your death only if the convenience signer is also
designated as a P.O.D. payee or trust account beneficiary. (1234)
Select one of the following accounts by placing your initials next to
the account selected: (1235)
___ (1) SINGLE-PARTY ACCOUNT WITHOUT "P.O.D." (PAYABLE ON
DEATH) DESIGNATION. The party to the account owns the
account. On the death of the party, ownership of the account
passes as a part of the party's estate under the party's will or by
intestacy. (1236)
Enter the name of the party: (1237)
_______________________________________________________
_________ (1238)
Enter the name(s) of the convenience signer(s), if you want one or
more convenience signers on this account: (1239)
_______________________________________________________
_________ (1240)
_______________________________________________________
_________ (1241)
___ (2) SINGLE-PARTY ACCOUNT WITH "P.O.D." (PAYABLE ON
DEATH) DESIGNATION. The party to the account owns the
account. On the death of the party, ownership of the account
passes to the P.O.D. beneficiaries of the account. The account is
not a part of the party's estate. (1242)
Enter the name of the party: (1243)
_______________________________________________________
_________ (1244)
Enter the name or names of the P.O.D. beneficiaries: (1245)
_______________________________________________________
_________ (1246)
_______________________________________________________
_________ (1247)
Enter the name(s) of the convenience signer(s), if you want one or
more convenience signers on this account: (1248)
_______________________________________________________
_________ (1249)
_______________________________________________________
_________ (1250)
___ (3) MULTIPLE-PARTY ACCOUNT WITHOUT RIGHT OF
SURVIVORSHIP. The parties to the account own the account in
proportion to the parties' net contributions to the account. The
financial institution may pay any sum in the account to a party at
any time. On the death of a party, the party's ownership of the
account passes as a part of the party's estate under the party's will
or by intestacy. (1251)
Enter the names of the parties: (1252)
_______________________________________________________
_________ (1253)
_______________________________________________________
_________ (1254)
_______________________________________________________
_________ (1255)
Enter the name(s) of the convenience signer(s), if you want one or
more convenience signers on this account: (1256)
_______________________________________________________
_________ (1257)
_______________________________________________________
_________ (1258)
___ (4) MULTIPLE-PARTY ACCOUNT WITH RIGHT OF
SURVIVORSHIP. The parties to the account own the account in
proportion to the parties' net contributions to the account. The
financial institution may pay any sum in the account to a party at
any time. On the death of a party, the party's ownership of the
account passes to the surviving parties. (1259)
Enter the names of the parties: (1260)
_______________________________________________________
_________ (1261)
_______________________________________________________
_________ (1262)
Enter the name(s) of the convenience signer(s), if you want one or
more convenience signers on this account: (1263)
_______________________________________________________
_________ (1264)
_______________________________________________________
_________ (1265)
___ (5) MULTIPLE-PARTY ACCOUNT WITH RIGHT OF
SURVIVORSHIP AND P.O.D. (PAYABLE ON DEATH) DESIGNATION.
The parties to the account own the account in proportion to the
parties' net contributions to the account. The financial institution
may pay any sum in the account to a party at any time. On the
death of the last surviving party, the ownership of the account
passes to the P.O.D. beneficiaries. (1266)
Enter the names of the parties: (1267)
_______________________________________________________
_________ (1268)
_______________________________________________________
_________ (1269)
Enter the name or names of the P.O.D. beneficiaries: (1270)
_______________________________________________________
_________ (1271)
_______________________________________________________
_________ (1272)
Enter the name(s) of the convenience signer(s), if you want one or
more convenience signers on this account: (1273)
_______________________________________________________
_________ (1274)
_______________________________________________________
_________ (1275)
___ (6) CONVENIENCE ACCOUNT. The parties to the account own
the account. One or more convenience signers to the account may
make account transactions for a party. A convenience signer does
not own the account. On the death of the last surviving party,
ownership of the account passes as a part of the last surviving
party's estate under the last surviving party's will or by intestacy.
The financial institution may pay funds in the account to a
convenience signer before the financial institution receives notice
of the death of the last surviving party. The payment to a
convenience signer does not affect the parties' ownership of the
account. (1276)
Enter the names of the parties: (1277)
_______________________________________________________
_________ (1278)
_______________________________________________________
_________ (1279)
Enter the name(s) of the convenience signer(s): (1280)
_______________________________________________________
_________ (1281)
_______________________________________________________
_________ (1282)
___ (7) TRUST ACCOUNT. The parties named as trustees to the
account own the account in proportion to the parties' net
contributions to the account. A trustee may withdraw funds from
the account. A beneficiary may not withdraw funds from the
account before all trustees are deceased. On the death of the last
surviving trustee, the ownership of the account passes to the
beneficiary. The trust account is not a part of a trustee's estate
and does not pass under the trustee's will or by intestacy, unless
the trustee survives all of the beneficiaries and all other trustees.
(1283)
Enter the name or names of the trustees: (1284)
_______________________________________________________
_________ (1285)
_______________________________________________________
_________ (1286)
Enter the name or names of the beneficiaries: (1287)
_______________________________________________________
_________ (1288)
_______________________________________________________
_________ (1289)
Enter the name(s) of the convenience signer(s), if you want one or
more convenience signers on this account: (1290)
_______________________________________________________
_________ (1291)
_______________________________________________________
_________ (1292)
Amended by: (1293)
Acts 2011, 82nd Leg., R.S., Ch. 91, Sec. 8.005, eff. January 1, 2014.
(1294)
Text of section effective on January 01, 2014 (1295)
NEW ACCOUNT APPLICATION
Type of Account Applying for ——————————————————————————————— Purpose of Account □ Consumer □ Business
Who Recommended Us to You? —————————————————————————————————————————————————————
ATM CASH CARD REQUEST
PIN # ———————————————————————
FOR INSTITUTION USE
Checking Account No. ___________________________
Savings Account No. ____________________________
Date ——————————————
Account No. ———————————
Approved □ By —————————
Declined □ By —————————
(Caution: For security reasons do not select your SSN, Date of Birth or other
separately discoverable number as the PIN.)
Number of Cards Requested ______________
Number of Cards Received _______________
OWNERSHIP OF ACCOUNT
□
□
Not all forms of ownership may be allowed in your state. Check with your financial institution.
Individual
□
Joint - With Survivorship
(and not as tenants in common)
□
Joint - No Survivorship
(as tenants in common)
Revocable Trust or Pay-On-Death Beneficiary
Name ———————————————————————————————————————————
Address ——————————————————————————————————————————
Name ———————————————————————————————————————————
Address ——————————————————————————————————————————
Unincorporated Nonbusiness Association of Individuals
□ Partnership
□ Limited Liability Company
Sole Proprietorship
□
□
Corporation:
For Profit
Not For Profit
TYPE OF ACCOUNT
□ Checking
□ Money
□ Savings
□ CD
Market
□ NOW
□ ————————————————
□ ————————————————
□
Initial Deposit $ ——————————
□ Cash □ Check No. ———————
□
□
Additional Information ———————
□ ——————————————————————————————————————————————— ——————————————————
Business ————————————————————————————————————————————
County and State
of Organization: —————————————————————————————————————————
Separate Authorization Received □ Yes □ No
Facsimile Signature □ Yes □ No
——————————————————
——————————————————
——————————————————
INDIVIDUAL APPLICANT INFORMATION
Name (Last, First, Middle)
Birth Date
Home Telephone No.
(
)
/
/
Present Address (Street, City, State & Zip)
Drivers Lic. No. / Passport No.
Do You □ Own
or □ Rent
Permanent Address
Social Security No.
County
How Long
County
How Long
Employer
How Long
Address
Position/Title
Telephone No.
(
)
How Long
Previous Employer (If Current Employer is Less Than —————— Years)
Address
Position/Title
Name and Address of Nearest Relative Not Living With You
Relationship
Telephone No.
(
)
Telephone No.
(
)
JOINT APPLICANT INFORMATION
Name (Last, First, Middle)
Birth Date
/
/
Address (Street, City, State & Zip)
Relationship
Telephone No.
(
)
Drivers License No.
Social Security No.
Employer
How Long
Address
Position
Telephone No.
(
)
Name and Address of Nearest Relative Not Living With You.
Relationship
Telephone No.
(
)
C © 1992 Bankers Systems, Inc., St. Cloud, MN
Form NAAP 7/11/2001
(page 1 of 2)
FINANCIAL INSTITUTION RELATIONSHIPS
Name of Financial Institution and Address
Type of Account
BANK OR OTHER CREDIT CARDS
Company
Account No.
Credit Limit
Balance
BACKUP WITHHOLDING CERTIFICATIONS
□
□
TAXPAYER I.D. NUMBER - My correct taxpayer identification number is: —————————————————————————————————
APPLIED-FOR TAXPAYER I.D. NUMBER - A taxpayer identification number has not been issued to me, and I mailed or delivered an application to
receive a taxpayer identification number to the appropriate Internal Revenue Service Center or Social Security Administration Office (or I intend to mail
or deliver an application in the near future). I understand that if I do not provide a taxpayer identification number to the payor within 60 days, the payor is
required to withhold the percentage allowed under the Internal Revenue Code of all reportable payments thereafter made to me until I provide a number.
□ EXEMPT RECIPIENTS - I am an exempt recipient under the Internal Revenue Service Regulations. (See below.)
□ BACKUP WITHHOLDING - I am not subject to backup withholding either because I have not been notified that I am subject to backup withholding
as a result of a failure to report all interest or dividends, or the Internal Revenue Service has notified me that I am no longer subject to backup withholding.
□ NONRESIDENT ALIENS - A separate certification has been or will be completed.
SIGNATURE: I certify under penalties of perjury the statements checked in this section and that I am a U.S. person (including a U.S. resident alien).
————————————————————————————————— DATE ———————————————————————————————
Payees Exempt from Backup Withholding
We are not required to backup withhold if the payee is:
and is paid in the course of the payer’s trade or
• A futures commission merchant registered with
• An organization exempt from tax under section
business and you have not provided your corthe Commodity Futures Trading Commission.
501(a) or an individual retirement plan.
rect taxpayer identification number to the payer.
• A real estate investment trust.
• The United States or any of its agencies or
• An entity registered at all times during the tax
instrumentalities.
• Payments of tax-exempt interest (including
year under the Investment Company Act of
• A state, the District of Columbia, a possession
exempt interest dividends under section 852).
1940.
of the United States, or any of their political sub• Payments described in section 6049(b)(5) to
• A common trust fund operated by a bank under
divisions, or instrumentalities.
nonresident aliens.
section 584(a).
• A foreign government or any of its political sub• Payments on tax-free covenant bonds under
• A financial institution.
divisions, agencies, or instrumentalities.
section 1451.
• A middleman known in the investment commu• An international organization or any of its agennity as a nominee or custodian.
cies or instrumentalities.
• Payments made by certain foreign organiza• A trust exempt from tax under section 664 or
Other payees that may be exempt from backup
tions.
described in section 4947.
withholding include:
• Payments of mortgage or student loan interest.
• A corporation.
Payments of interest not generally subject to
Payments that are not subject to information
• A foreign central bank of issue.
backup withholding include the following:
reporting are also not subject to backup withhold• A dealer in securities or commodities required to
•
Payments
of
interest
on
obligations
issued
by
ing. For details, see the regulations under secregister in the United States, the District of
individuals. Note: You may be subject to backtions 6041, 6041A, 6045, 6050A, and 6050N.
Columbia, or a possession of the United States.
up withholding if this interest is $600 or more
SIGNATURES
The undersigned acknowledge(s) receipt of a copy of and agree(s) to the terms of the following disclosure(s):
□ Truth in Savings
□ Electronic Funds Transfer □ Funds Availability □ Privacy □ —————————————————
I certify that everything I have stated in this application and on any attachments is correct. You may keep this application whether or not it
is approved. By signing below I authorize you to check my credit account and employment history and/or have a credit reporting agency
prepare a credit report on me, as an individual. I also authorize you to answer questions others may ask you about my credit record with
you. I understand that I must update credit information at your request if my financial condition changes.
————————————————————————————————
Applicant’s Signature
Date
————————————————————————————————
Joint Applicant’s Signature
Date
————————————————————————————————
Joint Applicant’s Signature
Date
Additional Authorized Signatories
————————————————————————————————
Signature
Relationship/Title
————————————————————————————————
Signature
Relationship/Title
————————————————————————————————
Joint Applicant’s Signature
Date
C © 1992 Bankers Systems, Inc., St. Cloud, MN
Form NAAP 7/11/2001
(page 2 of 2)