Inez Deposit Bank, FSB

DEPOSITOR

Account Number

Name (First - Middle - Last)

Address

City State Zip Code

How Long At This Address

Home Telephone

Own home Rent Live w/parents
[ ] [ ] [ ]

Monthly Rent/Mortgage

Previous Address (If Less than Three Years At Present Address)

Date of Birth

Social Security Number

Mother's Maiden Name

DEPOSITOR'S EMPLOYER

Employer

How Long:

Address

City State Zip Code

Position-Job Title

Annual Income

Telephone Number

NOTICE: You need not list income from alimony, child support
or separate maintenance if you do not want it considered

JOINT DEPOSITOR

Name (First - Middle - Last)

Issue another card in this
name: [ ] Yes [ ] No

Address (if different from depositor)

City State Zip Code

Date of Birth

Social Security Number

JOINT DEPOSITOR'S EMPLOYER

Employer

How Long?

Address

City State Zip Code

Position-Job Title

Annual Income

Telephone Number

Signatures: By signing below, the undersigned request(s) the described services and agrees to the terms and conditions governing the services, including any fees and charges. The undersigned agree(s) that all information is accurate and authorizes the financial institution to verify credit and employment history by any necessary means, including preparation of a credit report by a credit reporting agency.

_{-------------------------------------------------------------------------
---------------------}Signature of Depositor Date

_{-------------------------------------------------------------------------
---------------------}Signature of Joint Depositor Date
Mail or deliver application to:

INEZ DEPOSIT BANK, FSB
202 EAST MAIN STREET
P.O. BOX 689
LOUISA, KENTUCKY 41230

CURRENT DEBTS (Please attach another sheet if additional space is needed)
(check one or both)		Creditor	Mailing Address	Present Balance	Monthly Payments
Depositor (1)	Joint Depositor
(2)
(3)