PLEASE USE BIG LETTERS Date:

Employer: BANK USE ONLY

Wilderness
OLB:
Occupation:
PIN:
First/Given Name:
Passcode:
Last/Sur Name:
Salesforce:
SSN:
Recap:
Identification # From Home:
W8:
Birthday:

Phone Number: Account #:

Mother's Last Name at HER BIRTH:

Email Address:

Online Banking User ID:

Passport #: Issue Date: Exp Date:

J1 Visa # (RED#): Issue Date: Exp Date:

Address information in the US

Street Address: 511 E Adams St Room #:

City: Wisconsin Dells State/Province: WI

Country: United States Postal Code: 53965

Address information in your HOME COUNTRY

Street Address:

City: State/Province:

Country: Postal Code:

Verbal Passcode

City where you were born?

 W-8BEN Checklist
BMO Harris employees must complete this checklist when opening an account for a customer who is a nonresident alien.
IMPORTANT:
The account will be closed on the thirtieth calendar day from account opening if the W-8BEN form and checklist are
not completed accurately.
The completed W-8BEN form and checklist MUST be scanned using the Deposit Documents button.
Banker Name: ________________________________
Connie Cook Banker Phone: ________________________
608-254-2514 BUC#:__________
9180

Customer Name: ___________________________________________________________________________________

Customer Acct #: ________________________________________ Customer Phone: ___________________________

Section 1: Review of the W-8BEN Form (to be completed by the BMO Harris employee) Yes No
Form W-8BEN Part 1
Field 1 – Is the customer's name listed on the W-8BEN form? ✔
Field 2 – Is the country of citizenship listed without abbreviations on the W-8BEN form? The
✔
customer enters information in this field manually.
Field 3 – Is the permanent residence address listed on the W-8BEN form? ✔
Field 4 – Is there a mailing address listed on the W-8BEN form? If the customer has a U.S.
✔
address on the account, the U.S. address is listed as the mailing address on the W-8BEN form.
Field 5 – A U.S. taxpayer identification number (TIN) is optional.
Field 6 – Is a Foreign TIN provided? BMO Harris requires a foreign TIN for all NRA’s*. NRA’s
cannot be added to an account, or an account cannot be opened for them, if the NRA is unable to
provide a foreign TIN.
*Customers from the countries listed in the Foreign Tax ID and Date of Birth Information section in ✔
the W-8BEN Form Completion for Non-Resident Alien Individuals D&P may either provide a
foreign TIN or an explanation, printed on the bottom of the W-8BEN form, explaining why they
cannot provide this number.
Field 7 – Does the W-8BEN include the account number(s)? ✔
Field 8 – Is the date of birth listed on the W-8BEN form? ✔
Form W-8BEN Part 2
You do not need to complete Part 2 of the W-8BEN form for a deposit account.
Form W-8BEN Part 3
Has the customer signed, dated, and printed their name on the bottom of the W-8BEN form? ✔
If the customer has not provided a foreign TIN because their country of citizenship does not issue
✔
them, have they provided an explanation in the space at the bottom of the W-8BEN form?
If all the responses to Section 1 are “Yes,” continue to Section 2.

Section 2: Review for Indicia of U.S. Ownership

Yes No
(to be completed by the BMO Harris employee)
Is this person classified as a U.S. citizen anywhere in our account information? ✔
Do we have a current permanent residence address or mailing address in the U.S. as part of the
✔
account information provided by the person? Refer to Field 4 on the W-8BEN form.
Is there a current permanent residence address or mailing address in the U.S. on the W-8BEN
✔
form?
Is there a current telephone number for the person in the U.S.? U.S. fax numbers are considered
✔
telephone numbers.
Is there documentation, such as a passport, that indicates a U.S. place of birth? ✔

06.06.F1 Page 1 of 3 02/22/2018

 Section 2: Review for Indicia of U.S. Ownership (continued)
Yes No
(to be completed by the BMO Harris employee)
Does the customer have a green card (you do not need to view the card)? ✔
Determine the following:
If the answers to all of the questions in Section 2 are “No,” the W-8BEN may be accepted and the customer’s
signature is not required on the checklist.
If the answer to any one of the questions in Section 2 is “Yes,” the customer must complete a W-9 as a U.S.
resident. If the person has a reasonable explanation to claim W-8 status and decides not to complete the
Substitute W-9, give the checklist to the person and ask the person to complete Section 3.

Section 3 : Reasonable Explanation Supporting the Claim of W-8BEN Status

(to be completed by the customer)
If the customer needs to complete Section 3:
Refer to the W-8BEN Form Completion for Non-Resident Alien Individuals D&P for information on the Substantial
Presence Test.
Please note: If the customer states they have a closer connection to a foreign country, you must contact the BMO
Harris Tax Department at us.taxreporting@bmo.com for further instructions.

Yes No
Do you have student VISA status? – OR – ✔
Do you have teacher VISA status? – OR – ✔
Do you have diplomat VISA status? ✔

If a customer answers “Yes” to any of these questions, the customer is considered a nonresident alien, and BMO
Harris may accept a W-8BEN form. The customer signs and dates the form below.
If the customer answers “No” to all of these questions, ask the customer to complete the Substantial Presence Test (n
the next page) to determine whether they pass or fail the Test.

06.06.F1 Page 2 of 3 02/22/2018

 Substantial Presence Test (to be completed by the customer) Pass Fail
✔
To pass the Substantial Presence Test, must have been physically present in the U.S. for more than 31 days so far
this calendar year, or expect to be present in the U.S. 31 days during this calendar year.
— AND —
183 days during the three-year period that includes the current calendar year and the two years immediately
before that, counting:
All the days you have been in the U.S. so far this year, plus all the days you expect to be in the U.S. this
calendar year.
— AND —
1/3 of the days you were physically present in the first calendar year before the current year.
— AND —
1/6 of the days you were physically present in the second calendar year before the current year.

Example:
John Doe was physically present in the United States for 120 days in each of the years 2014, 2013, and 2012. To
determine if John passes the substantial presence test for 2014, count the full 120 days of presence in 2014, 40 days
in 2013 (1/3 of 120), and 20 days in 2012 (1/6 of 120). Since the total for the three-year period is 180 days (120 + 40 +
20), John fails the Substantial Presence Test, is not considered a U.S. Person for 2014, and would complete a W-
8BEN form.

Note:
Any time that the customer was in the U.S. on a student, teacher, or diplomat visa does not count toward the
Substantial Presence Test. If the customer indicated “Yes” for any one of the first three questions listed above, do not
include the days they were present in the U.S. using this visa in the calculations for the Substantial Presence Test.

If the customer Passes the Substantial Presence Test, they must complete a W-9 form, not a W-8BEN form.
If the customer Fails the Substantial Presence Test, they may complete a W-8BEN form.
Note, if the customer completes a W-8BEN form, a recertification of tax status is required every three years.
The customer should notify BMO Harris if their tax status changes.

Customer Signature: ____________________________________________________ Date: ______________________

06.06.F1 Page 3 of 3 02/22/2018

Form W-8BEN Certificate of Foreign Status of Beneficial Owner for United
(Rev. July 2017) States Tax Withholding and Reporting (Individuals) OMB No. 1545-1621
Department of the Treasury For use by individuals. Entities must use Form W-8BEN-E.
Internal Revenue Service Go to www.irs.gov/FormW8BEN for instructions and the latest information.
Give this form to the withholding agent or payer. Do not send to the IRS.
Do NOT use this form if: Instead, use Form:
• You are NOT an individual W-8BEN-E
• You are a U.S. citizen or other U.S. person, including a resident alien individual W-9
• You are a beneficial owner claiming that income is effectively connected with the conduct of trade or business within the U.S.
(other than personal services) W-8ECI
• You are a beneficial owner who is receiving compensation for personal services performed in the United States 8233 or W-4
• You are a person acting as an intermediary W-8IMY

Note: If you are a resident in a FATCA partner jurisdiction (i.e., a Model 1 IGA jurisdiction with reciprocity), certain tax account information may be
provided to your jurisdiction of residence.
Part I Identification of Beneficial Owner (see instructions)
1 Name of individual who is the beneficial owner 2 Country of citizenship

3 Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address.

City or town, state or province. Include postal code where appropriate. Country

4 Mailing address (if different from above)

511 E ADAMS ST
City or town, state or province. Include postal code where appropriate. Country
WISCONSIN DELLS, WI 53965 UNITED STATES
5 U.S. taxpayer identification number (SSN or ITIN), if required (see instructions) 6 Foreign tax identifying number (see instructions)

7 Reference number(s) (see instructions) 8 Date of birth (MM-DD-YYYY) (see instructions)

Part II Claim of Tax Treaty Benefits (for chapter 3 purposes only) (see instructions)
9 I certify that the beneficial owner is a resident of within the meaning of the income tax treaty
between the United States and that country.

10 Special rates and conditions (if applicable—see instructions): The beneficial owner is claiming the provisions of Article and paragraph
of the treaty identified on line 9 above to claim a % rate of withholding on (specify type of income):
•

Explain the additional conditions in the Article and paragraph the beneficial owner meets to be eligible for the rate of withholdings:

Part III Certification

Under penalties of perjury, I declare that I have examined the information on this form and to the best of my knowledge and belief it is true, correct, and complete. I further
certify under penalties of perjury that:

• I am the individual that is the beneficial owner (or am authorized to sign for the individual that is the beneficial owner) of all the income to which this form relates, or
am using this form to document myself for chapter 4 purposes,
• The person named on line 1 of this form is not a U.S. person,
• The income to which this form relates is:
(a) not effectively connected with the conduct of a trade or business in the United States,
(b) effectively connected but is not subject to tax under an applicable income tax treaty, or

(c) the partner's share of a partnership's effectively connected income,

• The person named on line 1 of this form is a resident of the treaty country listed on line 9 of the form (if any) within the meaning of the income tax treaty between
the United States and that country, and
• For broker transactions or barter exchanges, the beneficial owner is an exempt foreign person as defined in the instructions.

Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income of which I am the beneficial owner or
any withholding agent that can disburse or make payments of the income of which I am the beneficial owner. I agree that I will submit a new form within 30 days
if any certification made on this form becomes incorrect.

Sign Here
Signature of beneficial owner (or individual authorized to sign for beneficial owner) Date (MM-DD-YYYY)

Print name of signer Capacity in which acting (if form is not signed by beneficial owner)
For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 25047Z Form W-8BEN (Rev. 7-2017)

BUC#: By: Date:12/18/2018 09:33:54 CST Form: LIB-W8BEN.1217 Work Item ID:
 Personal Banking
Thank you for taking the time to meet with us. As a bank focused on outstanding customer experiences, we believe good communication is the foundation of
great service. That’s why we’d like to provide you with this meeting recap. It outlines the decisions we made, as well as next steps. If you have any
questions, our experienced bankers are at your service to listen and to provide you with the answers needed to help you make the right banking decisions.
Date
Branch Location
9180
Attendees
Account Number(s)
Next appointment
Date
Referral appointment
BMO Harris Premier Banker
BMO Harris Financial Advisor
Mortgage Banker
BUC#: By:
REVISED: May 2018
You opened: You requested:
Checking Accounts Overdraft Service
• BMO Harris Smart AdvantageTM Account ✔ • Overdraft Program for ATM and Everyday
Debit Card Transactions
• BMO Harris PremierTM Account
Overdraft Protection
• BMO Harris Smart MoneyTM Account • Overdraft Funding
Savings Accounts • Overdraft Protection Line of Credit
• Platinum Money Market Retirement Accounts
• Statement Savings • IRA Certificate of Deposit (CD)
Certificate of Deposit (CD) • IRA Premium Savers
IRA
Mortgages, Loans and Lines of Credit
Health Savings Account (HSA)
• Home Equity Loan or Line of Credit
You're interested in: • Personal Loan or Line of Credit
• Mortgage Referral
• Direct Deposit ✔
• Online Banking • Refi-Xpress
✔
• Mobile Banking • Auto Loan
✔
• Online Bill Pay Small Business needs
• Online Statements ✔ Disclosures provided ✔
Time You requested:
BMO Harris Debit Cards ✔
BMO Harris Credit Cards
• BMO Harris Bank Premium
Client Signature
Rewards Mastercard®
Date
• BMO Harris Bank Platinum
Rewards Mastercard®
• BMO Harris Bank Banker Signature
Date
Cash Back Mastercard®
• BMO Harris Bank Platinum
Mastercard®
Date
• BMO Harris Premier Services
Premium Rewards Mastercard®
Date:12/18/2018 09:31:23 CST Form: LIB-MEET-REC-P.0518 Work Item ID:
BMO Harris Bank at Work
and Group Banking Services
Checking Application

Directions
For Internal Use:
1. Choose the BMO Harris personal checking account you would like. IMPORTANT
2. Complete this application and signature card and return to your SR4
BAW Company Code for TPSS _______________________________
BMO Harris Banker or mail to BMO Harris Bank in the postage-paid
New account number _________________________________
envelope, or drop off at any BMO Harris branch location.

Yes, I want to apply for a BMO Harris personal checking account.

Type of Checking Account: SMART ADVANTAGE CHECKING

Joint Tenants with Rights of Survivorship Individual Marital (only available in Wisconsin)

Checking Account Application/Signature Card

Applicant Co-applicant (if applicable)
Name Name

Street Address Apt. Number Street Address Apt. Number

511 E Adams St
City, State, Zip Code City, State, Zip Code
Wisconsin Dells, WI 53965
Date of Birth Date of Birth

Primary ID (required): Primary ID (required):

Driver’s License Number Issuing State Driver’s License Number Issuing State

Issue Date (mm/dd/yy) Expiration Date (mm/dd/yy) Issue Date (mm/dd/yy) Expiration Date (mm/dd/yy)

Secondary ID (required): Secondary ID (required):

(if you have listed your Driver’s License as a Primary ID, you cannot use a State ID as (if you have listed your Driver’s License as a Primary ID, you cannot use a State ID as
Secondary ID) Secondary ID)

Type Description Number Type Description Number

J1 VISA
Issue Date (mm/dd/yy) Expiration Date (mm/dd/yy) Issue Date (mm/dd/yy) Expiration Date (mm/dd/yy)

Home Telephone Business Telephone Home Telephone Business Telephone

Employer Name Employer Name

Wilderness
Employer Address Employer Address
501 E Adams St, Wisconsin Dells, WI 53965
Occupation Occupation

(Page 1 of 2)
W-9 Information for applicant
Under 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 as a result of a failure to report all interest or dividends, or (c) the IRS has
notified me that I am no longer subject to backup withholding and
3. I am a U.S. citizen or other U.S. person as defined by the Internal Revenue Code and explained on IRS Form W-9 and
4. I am exempt from Foreign Account Tax Compliance Act (FATCA) reporting.
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 you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement
arrangement (IRA), and, generally payments other than interest and dividends, you are not required to sign this Certification, but you must
provide your correct Tax ID Number (TIN).
Taxpayer Identification Number (TIN) Taxpayer Identification Signature Date

_______________________________________________________________________________________________________________________________________

Signature Card Authorization and Application

By signing below, I/we apply to open and maintain the type of deposit account(s) described above (the “Account(s)”) and acknowledge receipt
of the BMO Harris Bank N.A. Privacy Notice and the BMO Harris Handbook (the “Handbook”), which includes the Deposit Account Agreement
and the applicable Deposit Account Disclosure(s) (as such terms are defined in the Handbook).
I/We agree to the terms and conditions set forth in the Deposit Account Agreement. I/We agree that the Deposit Account Agreement governs
the ownership rights of the account owners listed in the title of the Account(s) above (the “Owners”) and all other deposit accounts that the
Owner(s) have with BMO Harris now or in the future. I/We also agree that, if this is an application for a checking or statement savings account,
it is my/our intention and desire to apply for a BMO Harris ATM or Debit Card(s).
In connection with these applications, accounts and services, I/we authorize BMO Harris to obtain consumer reports about me/us, including
regarding my/our credit and employment history, and to answer questions about BMO Harris’ experience with me/us. I/We further authorize
BMO Harris to use any credit history or other consumer report information obtained in connection with this application to suggest other
BMO Harris products to me/us. BMO Harris has the right to charge the Account(s) for any liabilities owed to BMO Harris or its affiliates by any
one of the Owners.

Checking Account Application/Signature Card

Applicant Co-applicant (if applicable)
Name (First, Middle Initial, Last) Name (First, Middle Initial, Last)

Social Security Number Social Security Number

Mother’s Maiden Name Mother’s Maiden Name

Intended Purpose/Use of Accounts Co-applicant’s Signature (Please use black ink only)
expenses
Origin of Funds
paycheck
Applicant’s Signature (Please use black ink only)

For Bank Use Only

Opened by BAW code
Connie Cook SR4
Phone Account number
6082542514
BUC Opening deposit amount
9180
Open date Officer code/area

For NOC use only

(Page 2 of 2)

Banking products and services are subject to bank and credit approval. BMO Harris Bank N.A. Member FDIC
© 2017 BMO Financial Group 9172APP (R5) (5/17)