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FIRST NATIONAL BANK OF ELK RIVER ACCOUNT <br /> 729 MAIN STREET NUMBER <br /> ELK RIVER, MN 55330 <br /> (763) 241-3637 ACCOUNT OWNER(S)NAME &ADDRESS <br /> ELK RIVER MUNICIPAL UTILITIES <br /> OWNERSHIP OF ACCOUNT - CONSUMER PURPOSE 13069 ORONO PARKWAY NW <br /> ❑ INDIVIDUAL ❑ PO BOX 430 <br /> ❑ JOINT - WITH SURVIVORSHIP and not as tenants In common) ELK RIVER MN 553 3 0-04 3 0 <br /> ❑ JOINT - NO SURVIVORSHIP as tenants m common) <br /> ❑ TRUST - SEPARATE AGREEMENT <br /> Revised Date: 03/04/08 <br /> ❑ REVOCABLE TRUST OR ❑ PAY-ON DEATH SIGNER CHANGES <br /> DESIGNATION AS DEFINED IN THIS AGREEMENT. <br /> Name and Address of Beneficiaries <br /> Li NEW E EXISTING <br /> TYPE OF ❑ CHECKING © SAVINGS <br /> ACCOUNT ❑ MONEY MARKET ❑ CERTIFICATE OF DEPOSIT <br /> ❑ NOW ❑ <br /> This is your (check one) MANAGED SAVINGS ACCT <br /> X Permanent ❑ Temporary account agreement <br /> Number of signatures required for withdrawal 1 <br /> OWNERSHIP OF ACCOUNT - BUSINESS PURPOSE FACSIMILE SIGNATURE(S) ALLOWED, ❑ YES E NO <br /> ❑ SOLE PROPRIETORSHIP [ 1 <br /> E CORPORATION J ❑FOR PROFIT NOT FOR PROFIT J <br /> ❑ PARTNERSHIP X <br /> ❑ The undersigned agree to the terms stated on every page of this <br /> BUSINESS further <br /> and acknowledge receipt of a completed copy. The undersigned <br /> COUNTY & STATE further authorize the financial institution to verify credit and <br /> CF & STATE <br /> r 1N employment history and/or have a credit reporting agency prepare a <br /> credit report on the undersigned, as individuals, The undersigned <br /> AUTHORIZATION DATED also acknowledge the receipt of a copy and agree to the terms of the <br /> following disclosurelsl: <br /> 01/31/86 ANGEL GMYREK <br /> DATE OPENED By Deposit Account ❑ Funds Availability ® Truth in Savings <br /> INITIAL DEPOSIT $ L I Electronic Fund Transfers ❑ Privacy © Substitute Checks <br /> ❑ CASH ❑ CHECK ❑ Schedule of Fees <br /> HOME TELEPHONE p 41(14L <br /> BUSINSIN ESS PHONE K (763) 441-2020 <br /> 11): <br /> DRIVER'S LICENSE # X 9"11414/Lil <br /> E-MAIL tslominski@elkriverutilities . com JEROME A TAKLE <br /> EMPLOYER I D 1l D 0 B <br /> MOTHER'S MAIDEN NAME D.L.n 7"O <br /> /Name and address of someone who will always know your locaton _ ICT <br /> 12f- [x eJf / <br /> RRl GUMPHREY <br /> ID. # ROB <br /> BACKUP WITHHOLDING CERTIFICATIONS D.L.# <br /> TIN: 41-6005125 <br /> (3): <br /> L TAXPAYER I.D. NUMBER - The Taxpayer Identification X <br /> Number shown above (TIN) is my correct taxpayer identification HN J D ETZ <br /> number. <br /> I D # n O B <br /> © BACKUP WITHHOLDING - I am not subject to backup D.L.# <br /> withholding either because I have not been notified that I am �] <br /> subject to backup withholding as a result of a failure to report all (4) C_— U'G <br /> interest or dividends, or the Internal Revenue Service has notified X <br /> me that I am no longer subject to backup withholding THERESA LOMINSKI <br /> ❑ EXEMPT RECIPIENTS - I am an exempt recipient under the I D N n n g <br /> Internal Revenue Service Regulations D.L.# <br /> SIGNATURE: I certify under penalties of perjury the statements Authorized Signer (Individual Accounts Only) <br /> checked in this section and that I am a U.S. person (including a [X <br /> U.S. resident alien). <br /> x 3 II Ca <br /> (Date) <br /> I D # DOB <br /> D.L.# <br /> Or 992 Bankers Systems Inc,St Cloud,MN Form MPSC LAZ MN 4/19,2004 (page 7 of 21 <br />