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SIGNATURE OF PRIMARY ACCOUNT HOLDER SIGNATURE OF SECONDARY ACCOUNT HOLDER
The Internal Revenue Service does not require your consent to any provision of this document other than the certification required to avoid backup withholding.
Chevy Chase Bank New Account Opening Form
AGREEMENT: By signing above, I (we) certify that everything on this form, including the Taxpayer Identification Number Certification printed below, is correct;
I (we) acknowledge that I (we) have received the Personal Account Rules & Regulations; I (we) authorize Chevy Chase Bank, a division of Capital One, N.A., to
verify any information on this form and to check my (our) credit and employment history; I (we) agree that my (our) use of any deposit and/or credit accounts
that you issue to me (us) at my (our) request will be subject to the rules and regulations, terms and conditions governing such accounts, receipt of which is hereby
acknowledged.
BANK USE ONLY NEW ACCOUNT #’s: ___________________________________________ ______________________________________________
CHECKING ACCOUNT OTHER ACCOUNT
Primary/Custodian Account Holder Information (please print) Secondary/Minor Account Holder Information (please print)
List name exactly as it will appear on the account: List name exactly as it will appear on the account:
Primary Account Holder (First Name, MI, Last Name) Secondary/Minor Account Holder (First Name, MI, Last Name)
Street Address Street Address
City State Zip City State Zip
( ) ( ) ( ) ( )
Day Time Phone Evening Phone Day Time Phone Evening Phone
Social Security Number (This will be used for tax reporting purposes) Social Security Number (This will be used for tax reporting purposes)
Drivers License Number State Issue Date Expiration Date Drivers License Number State Issue Date Expiration Date
Place of Employment Place of Employment Date of Birth
Date of Birth Successor Custodian Age of Majority (18/21)
Opening Deposit Chevy Chase Check Card/ATM Card Request
Primary Account Holder: (check only one)
Check enclosed in the amount of $ _________________________________
(Please make payable to Chevy Chase Bank; do not enclose cash.) Please issue me a: Chevy Chase Check Card or
ATM Card for use with the above account(s).
Type of Account Add the new account to my existing Check Card/ATM Card below.
I (we) would like to open the following:
Primary Account Holder (First Name, MI, Last Name)
Checking Account:
Platinum Banking Package Interest Checking Existing Card Number
Silver Banking Package No Minimum Checking Secondary Account Holder: (check only one)
Preferred 50 Banking Package Free Direct Deposit Checking
Please issue me a: Chevy Chase Check Card or
Student Banking Package
ATM Card for use with the above account(s).
Savings/Investment Account: Add the new account to my existing Check Card/ATM Card below.
Super Statement Savings Super Money Market
Young Savers - Custodian Premium Money Fund Secondary Account Holder (First Name, MI, Last Name)
Young Savers - Joint
Existing Card Number
Certificates of Deposit: TAXPAYER IDENTIFICATION NUMBER CERTIFICATION (Substitute
30-Day 90-Day 6-Month 9-Month IRS Form W-9): Under penalty of perjury, I certify that: 1) The number
12-Month 18-Month 24-Month 30-Month shown on this form is my correct taxpayer identification number (or I am
waiting for a number to be issued to me), 2) I am not subject to backup
36-Month 42-Month 48-Month 60-Month withholding because (a) I am exempt from backup withholding, or (b) I have
Other ______________________ not been notified by the Internal Revenue Service (IRS) that I am subject to
backup withholding as a result of a failure to report all interest or dividends,
Printed Checks or (c) the IRS has notified me that I am no longer subject to backup with-
holding, and 3) I am a U.S. person (including a U.S. resident alien).
I (we) would like checks printed with:
Name(s) only Name(s) and Address NOTE: You must cross out item 2 above if you have been notified by
Other Information ________________________________________________ the IRS that you are currently subject to backup withholding because
of underreporting interest or dividends on your tax return.
_________________________________________________________________
Check this box and cross out the TIN certification above if none
_________________________________________________________________
of the account holders are citizens or residents of the United States.
Backup withholding will apply unless each accountholder provides
BANK USE ONLY
Br. # _____________ Session # _____________ Date _____________ ACID ____________ an IRS Form W-8 or a TIN.
Package Code _____________________________ Legibility Check Welcome Kit Please enclose this form and your opening deposit
(DO NOT ENCLOSE CASH) in the envelope provided or mail to:
Acct. Open _______ Checks Ordered _______ Check Card ______ 2nd Check Card ______ Chevy Chase Bank • 6200 Chevy Chase Drive, Laurel, MD 20707
or bring it to any Chevy Chase Bank branch
2235 REV. 08/09
General Terms Applicable to all Account Ownerships
Subject to the specific terms applicable to my (our) account, Chevy Chase Bank, a division of Capital One, N.A. (“Chevy Chase Bank”), may act without
further inquiry in accordance with writings bearing my (our) signature(s), specimens of which are shown on the completed New Account Opening
Form. Chevy Chase Bank is authorized to accept for deposit to this account checks and other instruments payable to any one or more of the account
owners, and to supply any needed endorsement. Chevy Chase Bank is relieved of any liability regarding collection of all such items and will not be
liable for acts of its agents, or others or for any casualty. Any amount not collected plus any expenses incurred regarding this account may be charged
back to this account or to any account at Chevy Chase Bank held in the name of the account owner(s). Unless this agreement states otherwise, upon
the death of the party, the funds in a multiple- party account shall belong to the surviving party or parties.
Specific Terms Applicable to the Joint Checking Account Ownership
As joint tenants with right of survivorship, we direct Chevy Chase Bank to act without inquiry pursuant to writings bearing any one or more of our
signatures, and to pay any one of the survivor(s) at any time.
Instructions for Completing Certification Form
(Section references are to the Internal Revenue Code)
A. Purpose of Form – Chevy Chase Bank is required to penalty of $50 for each such failure unless your failure is due to
obtain your correct taxpayer identification number (TIN) to reasonable cause and not to willful neglect.
report to the IRS income paid to you. Use our Substitute IRS
Civil Penalty For False Information With Respect To
Form W-9 on our Account Opening documents to furnish
Withholding – If you make a false statement with no reasonable
your correct TIN to us (1) to certify that the TIN you are
basis that results in no imposition of backup withholding, you
furnishing is correct (or that you are waiting for a number to
are subject to a penalty of $500.
be issued); (2) to certify that you are not subject to backup
withholding; and (3) to claim exemption from backup Criminal Penalty For Falsifying Information – Willfully
withholding, if you are an exempt payee. Furnishing your falsifying certifications or affirmations may subject you to
correct TIN and making the appropriate certifications will criminal penalties including fines and/or imprisonment.
prevent certain payments from being subject to the backup
withholding. Misuse of TINs – If we disclose or use TINs in violation of
Federal law, we may be subject to civil and criminal penalties.
B. How To Obtain a TIN – If you do not have a TIN, you
should apply for one immediately. To apply, get Form Specific Instructions
SS-5, Application for a Social Security Number Card (for A. Name – (Primary Accountholder) If you are an individual,
individuals) from your local office of the Social Security generally provide the name shown on your social security card.
Administration. However, if you have changed your last name, for instance, due
C. If You Don’t Have a TIN – To complete the Substitute to marriage without informing the Social Security Administration
IRS Form W-9 if you do not have a TIN, indicate that you of the name change, please enter your first name and both the
have applied for one by inserting all zeros in the space for last names shown on your social security card and your new last
the TIN, and sign and date the certification. Generally, you name.
will then have 60 days to obtain a TIN and furnish it to B. Signing the Certification –
us. If we do not receive your TIN within 60 days, backup (1) Accounts Opened After 1983 – You must sign the
withholding, if applicable, will begin and continue until certification or backup withholding will apply. If you are
you furnish your TIN to us. We will backup withhold on subject to backup withholding and you are merely providing
any reportable interest payments made to your account, your correct TIN to us, you must cross out item “2” in the
regardless of whether you make any withdrawals. The certification section before signing the form.
backup withholding must begin no later than 7 business
days after we receive this form back. We are required (2) Exempt Payees and Payments – If you are exempt from
to refund the amounts withheld if your certified TIN is backup withholding, you should complete this form to avoid
received within the 60-day period and you were not subject possible erroneous backup withholding. Enter your correct
to backup withholding during that period. TIN on the Substitute IRS Form W-9, check the second
Note: Writing “000-00-0000” on the form means that you box of the certification, sign and date the form. If you are
have already applied for a TIN OR that you intend to apply a nonresident alien or foreign entity not subject to backup
for one in the near future. withholding, you must give us a completed Form W-8,
As soon as you receive your TIN, complete another Form Certificate of Foreign Status.
W-9, include your TIN, sign and date the form, and give it to (3) TIN “Applied For”– Follow the instructions under How To
us. Obtain A TIN, Section IB, above, sign and date the form.
D. What is Backup Withholding? – Persons making certain Signature – For a joint account, only the person whose TIN
payments to you are required to withhold and pay to the is shown as the primary accountholder should sign the
IRS approximately 30% of such payments under certain certificate.
conditions. This is called “backup withholding.” Interest Privacy Act Notice – Section 6109 requires you to furnish your
payments are subject to backup withholding. correct taxpayer identification number (TIN) to persons who
If you give us your correct TIN, make the appropriate must file information returns with the IRS to report interest, and
certifications, and report all your taxable interest on your certain other income paid to you, mortgage interest you paid, the
tax return, your payments will not be subject to backup acquisition or abandonment of secured property, or contributions
withholding. you made to an individual retirement arrangement (IRA). IRS
Certain payees and payments are exempt from backup uses the numbers for identification purposes and to help verify
withholding and information reporting. For instance, if your the accuracy of your tax return. You must provide your TIN
account is an IRA or Keogh Retirement Plan. Ask us for a whether or not you are required to file a tax return. Payers must
list of exempt payee categories. generally withhold approximately 30% of taxable interest, and
Penalties certain other payments to a payee who does not furnish a TIN to
a payer. Certain penalties may also apply.
Failure to Furnish Correct TIN – You are subject to a
