CD-ROM Statement Request Form
Customer/Business Name: __________________________ SS/Tax ID: _________________ Mailing Address:_____________________________________________________________ City __________________________ State ______________ Phone: ____________________________ Listed ____ yes Zip ____________________ _____ no
Choose to receive a monthly, quarterly, or entire year’s statement on a CD-ROM. $15 monthly per CD-ROM per month with a free year-end CDROM. Do you want to receive a monthly printed statement? (Quarterly and yearend statement customers will receive a monthly, printed statement.) Yes No $65 per year-end CD-ROM with all your statements for the entire year.
$25 quarterly per CD-ROM per quarter with a free year-end CD-ROM.
List the statement account numbers, or primary account number for your Combined Statement to be included on your CD-ROM statement. Account Numbers: Type (checking, savings):
Do you want to include the back side of your check images? Yes No
Do you want to include the statement text? Yes No
Signatures: By signing below, the undersigned request(s) the described services and agrees to the terms and conditions governing the services, including any fees and charges. Applicant’s Signature ___________________________________ Date _________________
Additional Information Request When Opening a New Account To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person. Please include a photocopy of your driver’s license or other government issued photo ID.
Please deliver your completed form to any Berkshire Bank (link locations page), or mail to: Berkshire Bank Web Support P.O. Box 1308 24 North Street Pittsfield, MA 01202