First Name: Last Name: Street Address: City: State: ZIP Code: Last 4 digits of Social Security Number:

Privacy Options:

Please choose how you would like us to handle sharing information about you and your Bell Bank accounts. If you have a joint account, your choices will apply to you individually; however any account holder may submit the privacy preferences on behalf of the other joint account holders. If you submit multiple forms we will honor your most recent submission

Do not allow your affiliates to use my personal information to market to me. Do not share my personal information with other financial institutions to jointly market to me.

FOR NORTH DAKOTA RESIDENTS ONLY

I authorize Bell Bank and its affiliates to share my personal information with nonaffiliates to market Bell Bank products and services to me. I authorize Bell Bank and its affiliates to share my personal information with nonaffiliates to jointly market financial products to me.