Certificate of Deposit Application

Primary Joint Account Holder Information

Subject to backup withholding: Yes No

Joint Account Holder (with right of survivorship)

Subject to backup withholding: Yes No

Account Titling Information

Individual Joint

I/We would like to apply for the following Certificate of Deposit:

Personal Business

* To open a Checking Accounts, Savings Account, Money Market Account, or Visa Check Card, you may complete this form online. You will also need to come into the bank to sign a signature card and provide additional information.

Taxpayer Identification Number Certification: Under the penalties of perjury, I certify that (1) the number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and (2) I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding, or (c) the IRS has notified me that I am no longer subject to backup withholding as a result of failure to report all interest or dividends, or (d) the IRS has notified me that I am no longer subject to backup withholding, and (3) I am a U.S. person (including U.S. resident alien).

Certification Instructions: You must cross out item (2) above if you have been notified by the IRS that you are currently subject to backup withholding because of under-reporting interest or dividends on your tax return unless you have received another notification form from the IRS that you are no longer subject to backup withholding.

I understand that if I do not provide a taxpayer identification number to Goldwater Bank within sixty (60) days, then Goldwater Bank is required to withhold twenty percent (20%) of all reportable payments thereafter made to me until I provide a number.

By submitting this application, I (each person jointly and severally) apply for the deposit account listed above. As a deposit account owner, I am subject to all of its bylaws and rules as amended from time to time. I certify that all information given is correct.

I agree to the terms and conditions for any accounts or services that I have now or in the future, and as they change from time to time. I agree at any time you may request information from others about my credit or accounts and that you provide to others experience information about me or my accounts with Goldwater Bank.

The Internal Revenue Service does not require your consent to any provision of this document other than certification required to avoid backup withholding. See Taxpayer Identification Number Certification below.