To apply for an account with The Farmers State Bank, please complete and print this application, then mail it or bring it with you to your local branch of The Farmers State Bank.

A representative from The Farmers State Bank may contact you to verify your account application. Feel free to contact us with any questions you may have.
 

IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING OR CHANGING AN ACCOUNT WITH THE FARMERS STATE BANK

Section 326 of the USA PATRIOT ACT requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account or changes an existing account. This federal requirement applies to all new customers and current customers. This information is used to assist the United States government in the fight against the funding of terrorism and money-laundering activities.

What this means to you: when you open an account or change an existing account, we will ask each person for their name, physical address, mailing address, date of birth, and other information that will allow us to identify them. We will ask to see each person’s driver’s license and other identifying documents and copy or record information from each of them.

All applicants must complete Section A.
If you are applying for a business deposit account, complete Sections A and B.
If you are applying for a business loan, complete Sections A and C.
If you are applying for both deposit and loan accounts, complete all three sections.

If you work in Kansas and reside outside of Kansas please contact us.
I am applying for:
(check all that apply) 		DEPOSIT ACCOUNTS
Free Checking
Regular Checking
500+ Checking
NOW Checking
Passbook Savings
Money Market Account
Certificate of Deposit
IRA
Credit Card
Debit Card
ATM Card		 LOANS
Agricultural
Commercial
Real Estate
SECTION A - General Information
Business Name:
 Business Type:
Business Address:
City:
 State:
KS		 Zip Code:
Mailing Address
(if applicable)
 City:
 State:
KS
Zip Code :
 Business Phone:
(please include area code)
 Email Address:
Fax:
 Tax ID Number:
 Date of Birth:
Authorized Signer Name:
 2nd Authorized Signer Name:
(if applicable)
 3rd Authorized Signer Name:
(if applicable)
Primary Contact:
 Title:
SECTION B - Deposit Account Information
CD Term:
(This is only if you choose a Certificate of Deposit)
CD Interest:
(This is only if you choose a Certificate of Deposit)
Amount of Initial Deposit:
How Initial Deposit Will Be Made: I will mail a check to The Farmers State Bank
Incoming Wire
Debit my existing account at The Farmers State Bank
Account Number
Debit my current Bank
(You will receive a form for authorization)
Bank Name
Account Number
ABA Number
Please Provide The Following Verification Information:
Name of Current Bank:
 Address of Bank:
 City:
State:
 Zip Code:
 Account Number :
Drivers License of Primary Contact:
SECTION C - Loan Application Information
Type of Loan:
 Briefly Describe Your Financing Needs:
Amount Requested:
 Length of Repayment Requested:

Years     Months 		Annual Revenue / Sales:
(NOTE: 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 obligation)
Additional information that may be needed at time of contact: 3 years financial statements and/or tax returns, Interim financial statement, guarantors personal financial statements.
BY PRINTING AND SUBMITTING THIS INFORMATION TO THE FARMERS STATE BANK, I (WE) WISH TO APPLY FOR THE LOAN AND/OR DEPOSIT PRODUCTS LISTED ABOVE AND CERTIFY THAT ALL INFORMATION PROVIDED ABOVE IS CORRECT AND AUTHORIZE YOU TO CHECK MY (OUR) CREDIT AND VERIFY THE INFORMATION PROVIDED IN THIS APPLICATION. I (WE) ALSO CERTIFY UNDER PENALTY OF PERJURY THAT THE TAX ID NUMBER PROVIDED ABOVE IS CORRECT. I (WE) UNDERSTAND THAT ADDITIONAL INFORMATION MAY BE REQUIRED BEFORE A DECISION CAN BE MADE REGARDING THIS APPLICATION. I (WE) FURTHER UNDERSTAND THAT APPROVAL BY THE FARMERS STATE BANK FOR ANY OF THE LOAN OR DEPOSIT PRODUCTS IS CONDITIONED ON MY (OUR) AGREEMENT TO ABIDE BY ALL TERMS AND CONDITIONS CONTAINED IN THE APPLICABLE LOAN AGREEMENT AND/OR DEPOSIT AGREEMENT. I FURTHER AGREE TO RETURN ANY ACCESS DEVICE FOR OBTAINING FUNDS FROM ANY TYPE OF ACCOUNT UPON DEMAND BY THE FARMERS STATE BANK.

 

___________________________________________________
Authorized Signer's Signature

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CIRCLEVILLE / HOLTON KANSAS
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