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First Name *

Last Name *

Street Address *

Mailing Address *

City *

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Zip *

Email *

Last Four of Social *

Date of Birth *

Cell # *

Home # *

Work # *

Employer *

Occupation *

Driver's License Number *

Issuing State *

Issue Date *

Expiration Date *

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Thank you for your account inquiry with Libertyville Savings Bank. Upon receipt of this form, a new accounts representative or loan officer will contact you to complete an account application for the account type that would best fit your needs. Please note that this is only an inquiry and an application must be completed and approved prior to any account opening.

IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT: To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask you for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents. If you are under age 18, you must apply for an account in person at one of our offices with a parent or guardian.

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