Consumer Account Application

Consumer Account Application Bank Name: Store Name. WELLS FARGO BANK, N . A . BELLEVIEW & KIPLING Banker Name: OfficeriPortfoGo Number: Dater BEEVERS, CHARLES L6623 11/17/2016 Banker Phone: WELLS FARGO Store Number Banker AU: • 06623 To help the government fight the funding of terrorism and money laundering activities, U.S. Federal tom-quires financial institutions to obtain, verify, and record information that identifies each person (individualsand businesses) who opens an account. What this means for you: When you open an account we will ask too you name, address, date of birth and other information that will allow us to identify you. We may also ask to see your driver's licenses oche, identifying documents. New Account Information Product Name: Account Number. Product: Wells Fargo Everyday Checking IDDA Purpose of Account. Motor COID. Personal/Household 1163 New Account lGt Chedcing/Savings Bonus Offer Available: I NO Related Customers Customer Name. CARLOS PEREZ Statement Mailing Information Account Relawnslup Sole Owner Customerfs) Listed on Statement [CARLOS PEREZ D5G6921 (5.16 SW ) Statement Mailing Address: Address Line 2. City. State: ZIP:Postal Code. 2W02-000865833262-01 Country. US Page I of 2 Wells Fargo Confidential EFTA00125032 Consumer Account Application Customer 1 Information Customer Name CARLOS PEREZ Customer Number a (NJ Street Address. Address tme 2. Account Relationship: Sole Owner Tawayer Identification Number (TIN): TIN Type: ISSN Date of Birth: Primary ID Type: Primary ID Description: 111.1011101.1111111_ Secondary ID type: Secondary ID Description: OTHR EM DEPARTMENT OF JUSTICE Address Une3: City ZIP/Postal Code: Country. US State • Timeat thisaddress: 4 Year(s) 10 /Aondris) Directional Address' (Document alien no physical residence, business of alternatestreet address.) Secondary IDStateKountry. Secondary IDIssueDate: Secondary ID Expiration Date: CO '03/31/2015 Home Phone Rosiness Phone Current Employer (Butner Prison Check Reporting: NO RECORD Customer Signatures Everything I have stated in this application is correct. You are authorized to make any inquiries that you consider appropriate to determine if you should open or maintain the account. This may include ordering a credit report or other report 0.e. information from any motor vehicle department or other state agency) on me. I have received a copy of the applicable account agreementand the privacy policy (each may be amended from time to time)and agree to be bound by their terms. I also agree to the terms of the dispute resolution program described in the foregoing agreements. Under the dispute resolution program, our disputes will be decided before one or more neutral persons in an arbitration proceeding and not by a jury trial or a trial before a judge. Previous Street Address: 2IP/Postal Code. Country CountryWin/en/lip: US State 111114: at this address Yeahs) Months) Customer 1 Name CARLOS PEREZ Customer I Signalise Submit manually E Signature not required Date 11/17/2016 Page 2 of 2 Wells Fargo Confidential DSG8921 (5-16 SW ) 2W02-000865833262-0. EFTA00125033