Wisconsin Community Bank

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Wisconsin Community Bank — Personal Savings Application

You must be 18 years of age and a Wisconsin resident to apply for an account over the Internet. If you are under 18 years of age, please visit one of our offices or call Madison Market: 608-203-1200, Monroe Market: 608-328-4000.

Please Select Account

Regular Statement Savings

High Yield Savings

Regular Money Market

Premium Money Market

Certificates of Deposit

Individual Retirement Account CD

Ownership

Single Owner (individual)

Joint (right to survivorship)

Joint (no right to survivorship)

Payable on Death (POD)

Primary Account Owner

Name (First M. Last)

Date of Birth (mm/dd/yyyy)

SSN

Address

City, State Zip-Plus4 , -

Home Phone Number ( ) -

Work Phone Number ( ) -

Driver's License Number State

Email

Joint Account Owner (if you selected joint account ownership)

Name (First M. Last)

Date of Birth (mm/dd/yyyy)

SSN

Driver's License Number State

Payable on Death Beneficiary (if you selected POD ownership)

Name (First M. Last)

SSN

Phone Number ( ) -

Address

City, State Zip-Plus4 , -

Deposit Information

Initial Deposit $

Initial Deposit Type

Taxpayer Identification Number Certification

Social Security Number(s) The Social Security Number(s) shown above is my correct SSN.

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.

Exempt Recipients I am an exempt recipient under the Internal Revenue Service Regulations.

I certify under penalties of perjury the statements checked in this section are true.

I authorize the bank to obtain a copy of my current credit report as a condition of acceptance of this application and for the purpose of extension of or renewal of credit.

I would like to access this account through Online Banking.

Required federal disclosures will be provided to you at the time of actual account opening.

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