Riverland Bank

Identification Notary Form



Identification (unexpired government-issued identification evidencing nationality or residence and bearing a photograph or similar safeguard):

q  Drivers License, Issue date / Expiration date

q  State Issued ID

q  Other ______________________________

q  Signature Card


Identification Box (photocopy identification document in this box).
















(photocopy identification document in this box)


For U.S. person, a U.S. taxpayer identification number (e.g. Social Security number, individual taxpayer identification number, or employer identification number); for non-U.S. persons, one or more of the following: a U.S. taxpayer identification number, passport number and country of issuance, alien identification card number, or number and country of issuance of any other government-issued document evidencing nationality or residence and bearing a photograph or similar safeguard


Identification Number: ___   ___   ___ - ___  ___   - ___ ___ ___ ___



I, _____________________________, certify that this is my appropriate social security number and current identification.



__________________________________________                                _______________________________

Customer Signature                                                                                        Date



Text Box:  
Notary signature _____________________________________

Notary Box 

                                                                                                                                                                USA Patriot Act


                                                                                                                                    Important Information About 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 for your name, address, date

                                                                                                                                    of birth and other information that will allow us to identity you.  We

                                                                                                                                    may also ask to see your driverís license or other identifying documents.