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PERSONAL ACCOUNT APPLICATION 409 Silverside Road, Suite 105 Wilmington, DE 19809 P.  555.9316 F.  385.5121 Banking Services Provided by The Bancorp Bank, MEMBER FDIC, EQUAL HOUSING LENDER PART 1: Personal Information - Primary Account Holder First Name: SSN: Permanent Address: City: Work Phone: Home Phone: State: Email: MI: Last Name: Driver’s License # and State Issued: Please Fill Out Completely Date of Birth: / Mother’s Maiden Name: Apt./Box#: Zip: / If you have lived at this address for less than two years, please provide your previous address, and a copy of your utility bill or other document to verify your current address. Previous Address: City: State: Apt./Box#: Zip: PART 2: Joint Account Holder Information First Name: SSN: Address: City: Work Phone: Home Phone: State: Email: MI: Last Name: Driver’s License # and State Issued: Date of Birth: / Mother’s Maiden Name: Apt./Box#: Zip: / PART 3: Loans Select Loan Product(s) and amount Personal Loan Personal Line of Credit (See www.thebancorpHSA.com for a Complete List of Accounts) Are you opening or do you have an HSA account with The Bancorp Bank HSA? Will the Personal Line of Credit be used as overdraft protection for your HSA account? Yes No Yes No PART 4: Reference Marketing code: Broker code: Please mail your completed application to The Bancorp Bank HSA, 409 Silverside Road, Suite 105, Wilmington, DE 19809. Version 7.0 PART 5: Employment/Income Occupation: Current Employer: Gross Annual Income: Other Income:* Years in this Field: Years with this Employer: *Alimony, child support or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this loan Own Rent Monthly Mortgage or Rent Payment: Mortgage Holder or Landlord: This application is for Individual Joint credit Primary Applicant initials Joint Applicant initials PART 6: Required Signatures Authorizations I/We authorize The Bancorp Bank to check my/our credit and employment history, and instruct any person or consumer reporting agency to compile and furnish any information it may have or obtain in response to such credit inquires. All information set forth in this application is declared to be a true representation of the facts and made for the purpose of obtaining the credit requested. I/We agree to notify The Bancorp Bank immediately in writing of any material change in the facts stated in this application. This loan and/or Line of Credit account is subject to all applicable rules and regulations adopted by The Bancorp Bank. My signature acknowledges my acceptance of the disclosures governing these accounts. The disclosures are available at www.thebancorpHSA.com. I/We have read and understand the above authorizations and all applicable rules and regulations: Primary Applicant - Signature Required Date: / / Joint Applicant - Signature Required Date: / / Under penalties of perjury, I certify that: 1. the number shown on this form is my correct taxpayer identification number (TIN) (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 under Internal Revenue Service (IRS) regulations, or (b) I have not been notified by the Internal Revenue Service that I am subject to backup withholding as a result of failure to report all interest or dividends, or (c) the Internal Revenue Service has notified me that I am no longer subject to backup withholding. 3. I am a U.S. citizen (including a U.S. resident alien). CERTIFICATION INSTRUCTIONS - You must cross out item 2 above if you have been notified by the Internal Revenue Service that you are currently subject to backup withholding because of underreporting interest or dividends on your tax return. THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT OTHER THAN THE CERTIFICATION REQUIRED TO AVOID BACKUP WITHHOLDING. Primary Applicant - Signature Required Date: / / Joint Applicant - Signature Required Date: / / Please mail your completed application to The Bancorp Bank HSA, 409 Silverside Road, Suite 105, Wilmington, DE 19809.
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