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FIRE 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 ❑ ELK RIVER MN 55330-5600 <br /> 0 JOINT •WITH SURVIVORSHIP(ano not as tenants,n common) <br /> ❑ JOINT• NO SURVIVORSHIP(as tenants m common) <br /> ❑ TRUST -SEPARATE AGREEMENT <br /> Revised Date: 02/07/07 <br /> ❑ REVOCABLE TRUST OR ❑ PAY ON-DEATH CHANGE IN SIGNERS <br /> DESIGNATION AS DEFINED IN THIS AGREEMENT <br /> Name and Address of Beneficiaries <br /> ❑ 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 2 <br /> OWNERSHIP OF ACCOUNT-BUSINESS PURPOSE FACSIMILE SIGNATUREIS)ALLOWED' ❑ YES ® NO <br /> ❑ SOLE PROPRIETORSHIP rX <br /> ❑ CORPORATION: © FOR PROFIT ❑ NOT FOR PROFIT L <br /> ❑ PARTNERSHIP <br /> ❑ The undersigned agree to the terms stated on every page of this <br /> BUSINESS: form and acknowledge receipt of a completed copy.The undersigned <br /> COUNTY S STATE further authorize the financial institution to verify credit and <br /> OF ORGANIZATION. employment history and/or have a credit reporting agency prepare a <br /> 0 2/ 20/0 7 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 disclosure(s): <br /> 01/31/86 ANGEL GMYREK <br /> DATE OPENED BY © Deposit Account ® Funds Availability ® Truth in Savings <br /> INITIAL DEPOSIT 9 © Electronic Fund Transfers ❑ Privacy © Substitute Checks <br /> ❑ CASH ❑ CHECK ❑ © Schedule of Fees <br /> HOME TELEPHONE <br /> BUSINESS PHONE N (7 6 3 ) 4 4 /020 <br /> DRIVER'S LICENSE N _ (1) X <br /> EMAIL JEROME A TAKLE <br /> EMPLOYER I D N 0 O B <br /> MOTHER'S MAIDEN NAME D.L-# <br /> Name and address of someone who will always know your location <br /> (2): LX <br /> JAMES A TRALLE <br /> I.D. # D O.B <br /> BACKUP WITHHOLDING CERTIFICATIONS D.L. <br /> TIN: 41-6005125 <br /> 13): <br /> © TAXPAYER I.D. NUMBER - The Taxpayer Identification X <br /> Number shown above (TIN) is my correct taxpayer identification JERRY GUMPHREY <br /> number. <br /> I.D N -_ D 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 (41: <br /> interest or dividends, or the Internal Revenue Service has notified X <br /> me that I am no longer subject to backup withholding. DItYRN C rd43 <br /> ❑ EXEMPT RECIPIENTS • I am an exempt recipient under the Ar- — 'D' ' - — <br /> Internal Revenue Service Regulations. D.L.# <br /> SIGNATURE: I certify under penalties of perjury the statements ❑Autnor zed S finer(Individual Accounts Only) <br /> checked in this section and that I am a U.S. person (including a f X <br /> U.S. resident alien). L <br /> X <br /> (Date) <br /> 1.0 N DOB <br /> `�1 01992 Bankers Systems.inc.SiCloud,MN Form MPSC-LAZ.MN 4/19/2004 D.L. <br /> e-+�L�er Ipage 1 0/2) <br />