APPLICATION FOR RETIREMENT ACCOUNTS

To open a new account, fill in the necessary information, print the form, and sign at bottom. 
Mail the completed form together with your opening deposit and copies of your photo identification to:

INTERVEST NATIONAL BANK
One Rockefeller Plaza, Suite 400
New York, NY 10020-2002

OR

 INTERVEST NATIONAL BANK
625 Court Street
Clearwater, FL 33756-5528

Type of Account:

Money Market Account
Certificate of Deposit 

Retirement Account Requested:
Traditional Individual Retirement Account (IRA)
Roth Individual Retirement Account (Roth IRA) 
Education IRA

Contribution Information:

Opening Deposit will be
Transfer from another institution
Rollover from another institution
Contribution for current year 
Contribution for prior year

Owner Information:

Name: (First/Middle/Last)
DOB: (MM/DD/YYYY) SSN: 
Address:
City: State:  Zip: 
Home Phone Number: Work Phone Number:
Employer:
Occupation:
(If Retired, kindly indicate last occupation)
Drivers License Number: State:  (Please provide copy)
Email Address:
 
Current Bank:
Bank Address:
Account #:

A. Primary Beneficiary

Name of Beneficiary SSN/TIN Relationship Date of Birth
%
%
%
%
Total 100%

B. Contingent Beneficiary

Name of Beneficiary SSN/TIN Relationship Date of Birth
%
%
%
%
Total 100%


Comments/Instructions:

Substitute W-9 Certification:  Please read entire statement before signing.  Check all that apply.
Social Security Number(s): The Social Security Number(s) shown above is my correct SSN. 
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 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. 
Nonresident Alien: I am not a United States person, or if I am an individual, I am neither a citizen nor a resident of the United States. 

I certify under penalties of perjury the statements checked in this section are true. 

I authorize INTERVEST NATIONAL BANK to obtain copy of my current credit report as a 
condition of acceptance of this account application and/or for the purpose of extension of or 
renewal credit. 


Signature
Date
Signature
Date

SEE OUR DISCLOSURES

Instructions For Filing Account Application: 

  1. Complete the application above. Please provide all requested information.

  2. Print the completed application and sign in the space provided. All account owners must sign.

  3. Copies of two forms of identification are required for each account owner. One of the ID's provided for each account owner must contain a photo, such as a driver's license or passport. Expired identification cards are not acceptable.

  4. Mail completed application with a photocopy of your photo identification together with your check for the opening deposit to: 

    INTERVEST NATIONAL BANK
    One Rockefeller Plaza, Suite 400
    New York, NY 10020-2002

    OR

    		 INTERVEST NATIONAL BANK
    625 Court Street
    Clearwater, FL 33756-5528


  5. The minimum deposit required to open an IRA certificate of deposit is $1,000.  The minimum deposit required to open an IRA money market account is $1,000.  We will open your account upon receipt of your deposit. We cannot hold or guarantee rates. Rates are subject to change without prior notice. If you wish to check current rates, click here. 
  6. You may fax your application to us and have your Bank send the funds via wire transfer if you wish to open your account immediately. Funds received after 2 P.M. will be processed on the next business day. An incoming wire charge of $15.00 will be deducted from your opening deposit. 
    Provide the following wiring instructions to your bank/broker:


    For Florida Division Accounts:

  7. We will send you the appropriate account documentation after your account is opened and the required account documentation is received by us. Failure to provide the required information may result in a delay in opening your account or your initial deposit may be returned.

Thank you for banking with Intervest National Bank.