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Certificate of Deposit Application
Submitter Information (Required)
First Name (required)
Last Name (required)
Resolve the errors marked in red before submitting again.

Privacy Policy:
Our privacy policy protects the privacy of your personally-identifying information that you provide us online.

Account Holders must reside in Bucks, Montgomery or Philadelphia County, Pennsylvania.

Important Information about Procedures for Opening a New Account
Identification Procedures Requirements: 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.

Security Notice:
You should ONLY fill out this Application on-line if you are using a browser with the latest security enhancements. If you don't have the latest version, download a copy now.

Instructions:
1. Complete Application and click "Submit Application" or fax it to 215-788-9084 or mail to Fidelity Savings, PO Box 605 Bristol PA 19007-0605.
2. To safeguard your privacy, QUIT your browser and restart it again after using this form. This form is NOT saved in your computer's memory when you quit your browser.
3. We will contact you with the location of our closest office for you to sign a signature card. You may also be requested to provide photocopies of your Social Security card and Driver's License, or other documentation.

Primary Joint Account Holder Information
First NameMiddle InitialLast Name

 

 

 
Date of BirthSocial Security No.Your E-mail Address

 

 

 
Home PhoneDriver's License No.Driver's License State

 

 

 
Address Information
Subject to backup withholding
Work Phone
Joint Account Holder (with right of survivorship)
First NameMiddle InitialLast Name

 

 

 
Date of BirthSocial Security No.Your E-mail Address

 

 

 
Home PhoneDriver's License No.Driver's License State

 

 

 
Address Information
Subject to backup withholding
Work Phone
Account Titling Information
In Trust For
NameSocial Security No.

 

 
Custodial
NameSocial Security No.

 

 
I/We would like to apply for the following Certificate of Deposit:
Term
Amount $

he Internal Revenue Service does not require your consent to any provision of this document other than certification required to avoid backup withholding. See Taxpayer Identification Number Certification below.

Taxpayer Identification Number Certification: Under the penalties of perjury, I certify that

(1) the number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and

(2) I am not subject to backup withholding because

    (a) I am exempt from backup withholding, or

    (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding, or

    (c) the IRS has notified me that I am no longer subject to backup withholding as a result of failure to report all interest or dividends, or

    (d) the IRS has notified me that I am no longer subject to backup withholding, and

(3) I am a U.S. person (including U.S. resident alien).

Certification Instructions: You must cross out item (2) above if you have been notified by the IRS that you are currently subject to backup withholding because of under-reporting interest or dividends on your tax return unless you have received another notification form from the IRS that you are no longer subject to backup withholding.

I understand that if I do not provide a taxpayer identification number to Fidelity Savings and Loan Association of Bucks County within sixty (60) days, then Fidelity Savings and Loan Association of Bucks County is required to withhold twenty percent (20%) of all reportable payments thereafter made to me until I provide a number.

By submitting this application, I (each person jointly and severally) apply for the Certificate of Deposit listed above. As a Certificate of Deposit owner, I am subject to all of its bylaws and rules as amended from time to time. I certify that all information given is correct.

I agree to the terms and conditions for any accounts or services that I have now or in the future, and as they change from time to time. I agree at any time you may request information from others about my credit or accounts and that you provide to others experience information about me or my accounts with Fidelity Savings and Loan Association of Bucks County.

I/We AGREE with the above statement