Checking, Savings, and Certificate of Deposit Account Application

To apply for your account(s), please completely fill out the application, print it and mail it with your opening
deposit instructions and photocopy(s) of your valid driver's license or state-issued photo ID to:

Cyber Banking
Mercantile Bank
P.O. Box 3455
Quincy, IL 62305-3455

Upon approval of your application and receipt of your opening deposit, Mercantile will open the account(s) requested and send you a receipt and other important information about your account(s). Accounts opened will be subject to Mercantile Bank's new account policies, rates, fees and balance waiver requirements. Your opening deposit should be made payable to Mercantile Bank. Note: All non-local deposits must be sent by wire transfer or other electronic transfer. If you have any questions regarding this application, please call us at 1-800-405-6372 and ask for Customer Service, or e-mail us.

NOTE: If you would like to name a beneficiary or have any other special account title requests, please attach a separate sheet
with your instructions and enclose any supporting documents necessary.

I. ACCOUNT SELECTION(S)

Checking Account:

Type of Account to Open

Initial Deposit
Please review our Funds Availability Policy

(min. opening deposit of $100)

Choose one of the following for your account:
Mercantile MasterMoney Card
(An ATM card that works like a check anywhere MasterCard is accepted)
Mercantile ATM Card
(Get cash at any ATM machine where you see the Cirrus or Shazam logos!)

 


Bank Use Only

Savings Account:

Type of Account to Open

Initial Deposit:
Please review our Funds Availability Policy

(Minimum opening deposit of $0 for Christmas Cash Club, $25 for Pennywise Savings, $50 for DreamBuilder Savings, and $100 for Blue Moon Savings and MClass Safety Sweep.)


Bank Use Only

Star Money Market Account:

Check Here to Select this Account

Initial Deposit:
Please review our Funds Availability Policy


(min. opening deposit of $1,000)


Bank Use Only

CD Time Deposit Account:

Type of Account to Open

Initial Deposit:
Please review our Funds Availability Policy


(min opening deposit of $1,000 on regular monthly terms. See rate chart for special CD promotion requirements.)


Bank Use Only

How do you want your interest paid?

Keep my money working - add to my principal

Send me a quarterly check

College Saver CD:

Type of Account to Open

Initial Deposit:
Please review our Funds Availability Policy


(min opening deposit of $100)


Bank Use Only

TOTAL OPENING DEPOSIT

Please review our Funds Availability Policy


(This is your total opening deposit amount for all accounts opened above.)


Bank Use Only

NOTE: All non-local deposits must be sent by wire transfer or other electronic transfer.

II. ACCOUNT HOLDER(S) INFORMATION

Primary Applicant's Information:
(include suffix (Jr., Sr.) if applicable)
 

Prefix

First Name

MI

Last Name

Suffix

Home Phone

Marital Status

Married
Separated
Unmarried

Date of Birth

/
/

 
Social Security Number

 
Address

City

State

ZIP

Own
Rent

No of years:

E-mail:

Joint Applicant's Information:
(include suffix (Jr., Sr.) if applicable)
 

Prefix

First Name

MI

Last Name

Suffix

Home Phone

Marital Status

Married
Separated
Unmarried

Date of Birth

/
/

 
Social Security Number

 
Address

City

State

ZIP

Own
Rent

No of years:

E-mail:

III. EMPLOYMENT INFORMATION

Primary Applicant's Employment:
 

Check if self-employed
 

Name of Employer

Address

City

State

ZIP

Phone

 

Type of Business

Position/Title

Years on the job

Years in this
Profession

Joint Applicant's Employment:
 

Check if self-employed
 

Name of Employer

Address

City

State

ZIP

Phone

 

Type of Business

Position/Title

Years on the job

Years in this
Profession

IV. PERSONALIZED CHECK ORDER INFORMATION

I (we) would like to receive checks for this account (complete the area below)

I (we) do not wish to receive checks for this account (move to Section V.)

Please list your personal information as you would like it to appear on your printed checks. Any optional fields left blank will not appear on your checks. You will receive your checks in the mail 2-3 weeks after we receive your deposit.

Applicant's Name

OPTIONAL FIELDS

Joint Applicant's Name

Phone Number

Street Address

Applicant's ID (Driver's License, SSN, etc.)

City State  ZIP

 

Joint Applicant's ID (Driver's License, SSN, etc.)

Additional Instructions:

V. CERTIFICATION
For Social Security Number verification purposes, please read and sign the following.

Under penalties of perjury, the undersigned certifies that: 1) the number on this form is my correct taxpayer identification number: (TIN) and 2) I am not subject to backup withholding because one of the following applies: I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of failure to report all interest or dividends or the IRS has notified me that I am no longer subject to backup withholding. You must cross out item( 2) above if you have been notified by the IRS that you are currently subject to backup withholding.

Check the appropriate boxes if applicable:

Foreign Recipient: I certify that I am neither a resident nor a U.S. citizen and therefore, I am not subject to backup withholding. Also, I've provided my permanent address to the bank.

Applied for TIN: I certify that a TIN has not been issued to me and that I have applied or intend to apply for a TIN. I understand that this account is subject to immediate withholding of 31% of any payments made to me until I provide a certified TIN to the bank. I further understand that if no TIN is provided within 60 days, the Bank has a right to close this account and deliver the proceeds to me, less any penalties and less any amounts withheld pursuant to this provision.

The certifications above do not apply to all signers. Individual certifications have been provided by all account owners.

The Internal Revenue Service does not require your consent to any provisions of this document other than the certifications required to avoid backup withholding.

 
Applicant
Signature

 

 
Applicant TIN
(Social Security Number/
Tax ID Number)

 

 
Joint Applicant
Signature

 

 
Joint Applicant TIN
(Social Security Number/
Tax ID Number)

 

VI. AUTHORIZATION TO OPEN ACCOUNT(S)

ACCOUNT AGREEMENT: Everything that is stated in this new account application is correct to the best of my (our) knowledge. I (We) give this information for the purpose of obtaining the type of account(s) stated on this application. I (We) authorize the Bank to obtain information concerning any statements made here; to answer any questions about its credit experience with me (us); and to share any information obtained concerning or contained in this application with third parties; including credit reporting agencies. I (We) understand that a credit report may be requested in connection with this application.

I (We) authorize the sharing of this application, any information relating to the account(s) opened and any information obtained concerning this application with any of the Bank's affiliates.

JOINT WITH RIGHT OF SURVIVORSHIP AGREEMENT (if more than one signature): We intend to and do hereby create a joint account with rights of survivorship.

I (We) understand and agree that when the Bank opens the account(s) requested, I (We) will be bound by the terms and conditions governing the accounts as they may be amended from time to time.

Applicant
(or custodian) if UGMA account

 

Date

 

Joint Applicant

 

Date

 

Bank Use Only (Name)

Bank Use Only (Acct #)

 

Enroll for Internet Banking Services! [6k]Double check to make sure the application is completely filled out, print and sign it, and mail it with your opening deposit instructions and photocopy(s) of your valid driver's license or state-issued photo ID to:

Cyber Banking

Mercantile Bank

P.O. Box 3455

Quincy, IL 62305-3455

 

Please Note: All non-local deposits must be sent by wire transfer or other electronic transfer.

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