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 consumer deposit account, complete Sections A and B.
If you are applying for a consumer 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
Consumer
Real Estate
Student
SECTION A - General Information
Last Name:
 First Name:
 Middle Initial:
Home Address :
 City:
 State:
KS		 Zip Code:
Mailing Address (if applicable):
 City:
 State:
KS		 Zip Code:
Previous Home Address:
 City:
 State:
 Zip Code:
Home Phone
(please include area code):
 Email Address:
 Fax:
Date of Birth:
 Social Security Number:
Employer:
 Employer Address:
City:
State:
 Zip Code:
Employer Telephone:
Years There:
Position / Title:
Previous Employer
(if less than 2 years with current employer):
  
Prev. Employer Address:
 City:
 State:
 Zip Code:
Joint Applicant Information
* You do not need to fill out this section unless you are applying for a joint application.
Last Name:
 First Name:
 Middle Initial:
Home Address :
 City:
 State:
 Zip Code:
Previous Home Address:
 City:
 State:
 Zip Code:
Home Phone (please include area code):
 Email Address:
 Fax:
Date of Birth:
 Social Security Number:
Employer:
 Employer Address:
City:
State:
 Zip Code:
Employer Telephone:
Years There:
Position / Title:
Previous Employer
(if less than 2 years at current employment):
Prev. Employer Address:
 City:
 State:
 Zip Code:
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 :
KS Drivers License or State Issue ID Number:
 Are you a US Citizen?
Yes
No
NOTE: If you do not have a drivers license or state issued ID, please call one of our Customer Service Representatives at (785) 364 - 4691
Nearest Relative Not Living With You:
 Address:
 City:
State:
 Zip Code:
 Phone Number (including area code):
Mother's Maiden Name (for security purposes):
The Following Service Is Subject To Credit Approval:
Would you like to apply for The Farmers State Bank Check Card?:
Yes     No
SECTION C - Loan Application Information
Purpose of Loan:

If the credit line or loan is for home purchase, refinance, construction-to-perm, repair or maintenance, the following information is requested by the Federal government to monitor this lender's compliance with the Equal Credit Opportunity and Fair Housing Laws. The law provides that a lender may neither discriminate on the basis of this information nor on whether or not it is furnished. If you do not wish to furnish this information please indicate below.

The creditor shall also inform the applicant(s) that if the applicant(s) chooses not to provide the information, the creditor is required to note the race or national origin and sex on the basis of visual observation or surname.
Applicant:
I do not wish to furnish this information
Race or National Origin:
 Ethnicity:
 Sex:
Co-Applicant:
I do not wish to furnish this information
Race or National Origin:
 Ethnicity:
 Sex:
Amount Requested:

Gross Annual Income:
Length of Repayment Requested:

(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)
Do you own your home (or other real estate you would offer as collateral):
Yes   No
If yes, please provide the value of that real estate:
Amount of First Mortgage:
 Amount of Second Mortgage:
BY PRINTING AND SUBMITTING THIS INFORMATION TO THE FARMERS STATE BANK, I (WE) 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 SOCIAL SECURITY NUMBER(S) PROVIDED ABOVE IS/ARE CORRECT AND THAT I AM NOT (WE ARE NOT) SUBJECT TO BACKUP WITHHOLDING UNDER THE INTERNAL REVENUE CODE. 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.

 

___________________________________________________
Applicant Signature

 Today's Date:

 

___________________________________________________
Co-Applicant Signature

 Today's Date:
Please click the 'Print this form' button below to print this form,
or click 'Reset all information' to clear out all information.
 
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CIRCLEVILLE / HOLTON KANSAS
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