Application for Checking,
Savings, or Certificate of Deposit Account
To open one of the above accounts at Leader Bank, N.A., Please complete the following information, print and mail to Leader Bank, N.A. 141 Massachusetts Avenue, Arlington, MA 02474. To open your account immediately, you can fax this form at
781-646-2857. All account applications subject to approval.
What Type Of Account Do You Wish To Open? (Click link for description)
What type of Certificate of Deposit Do You Wish To Open?
What type of Certificate of Deposit do you wish to open?
5 Year
18 Month
4 Year
15 Month
3 Year
6 Month
2 Year
1 to 3 Month
1 Year
Ownership of Account - Consumer Purpose
Individual
Joint
Trust - Separate Agreement
Initial Deposit Information
Initial Deposit
(Minimum $10):
If you are making your initial deposit via check, please make the check payable to:
Leader Bank, N.A. Bank for account of "your name".
Primary Applicant Information
Name (First /MI/ Last):
Social Security Number:
Date of Birth:
Mother's Maiden Name:
Home Address:
City/Town:
State:
Zip Code:
Mailing Address (if different):
Home Telephone:
Work Telephone:
E-Mail Address:
Employer:
Joint Applicant Information (Complete only if joint account)
Name (First /MI/ Last):
Social Security Number:
Date of Birth:
Mother's Maiden Name:
Home Address:
City/Town:
State:
Zip Code:
Mailing Address (if different):
Home Telephone:
Work Telephone:
E-Mail Address:
Employer:
Beneficiary (Complete only if there is a beneficiary)
Name (First /MI/ Last):
Address:
Relationship:
Date of Birth (Month/Day/Year):
Social Security Number:
Disclosures
Government regulations require that we make the following disclosures available to you when you apply for an account with Leader Bank. You may print these disclosures for your records, if you wish. Links to these disclosures
are available at http://www.leaderbank.com/disclosure_deposit_account.asp.
BACKUP WITHHOLDING CERTIFICATIONS
“**Primary Applicant MUST input
their social security number in the box below. Failure to do so
will cause delays in the opening of your new account.”
TIN:
By my signature below, I acknowledge and certify the following:
Taxpayer ID Number: The taxpayer identification number shown above (TIN) is my correct taxpayer identification number.
Backup withholding: I am not subject to backup withholding either because I have not been notified that I am subject to backup withholding as a result of a failure to report all interest or dividends or the Internal Revenue Service has notified me that I am no longer subject to backup withholding.
Exempt Recipients:
I am an exempt recipient under the Internal Revenue Service regulations.
I certify under penalties of perjury the statements checked in this section and that I am a U.S. person (including U.S. Resident Alien).
Each signatory authorizes the Bank to obtain consumer reports from any consumer reporting agency, including but not limited to a check protection service for use in connection with this account. The undersigned also agrees receipt of following disclosures.
I, (we) severally, agree to be bound by present or future by-laws, regulations or procedures of the Leader Bank, which are or may become applicable to this Account.
________________________________________________________________
Primary Applicant Signature
Date
________________________________________________________________
Joint Applicant Signature
Date
Please send this signed and completed application, along with your initial deposit and a copy of a picture ID (such as a drivers license)
and one more form of ID (copy of credit card/Employee card) to the address noted below. If your Social Security number is not evident on your driver's license, please furnish a copy of your Social Security card.
Customer Service Leader Bank, NA
Attn: Jay Tuli
180 Massachusetts Avenue
Arlington, MA 02474 Tel: 781-646-3900 Fax: 781-646-3910
You should receive your new account information within approximately 5 days. Click here for an application for a free ATM or debit card. (Not available on Certificates of Deposit or Statement Savings Accounts.) Your new checks should arrive within 2 weeks. If you have any questions, please call
1-781-641-3900.
