* 1. Were you a participating Basic Banking for Massachusetts financial institution in 2016?

* 2. Please type the name of your financial institution as you would like it to appear on our website:

* 3. I certify that my financial institution has BOTH a qualified Basic Banking for Massachusetts Checking Account and a Basic Banking for Massachusetts Savings Account. This means the accounts meet all of the following criteria.

Basic Banking Checking Account Guidelines:
- Requires no more than $25.00 to open the account
- Charges a monthly fee of no more than $3.00
- Provides at least 15 free withdrawals, including at least eight (8) checks, per month
- Charges no more than $1.00 for each withdrawal over the allowable number of free withdrawals

Basic Banking Savings Account Guidelines:
- Requires no more than $10.00 to open an account
- Charges no monthly fee on account balances of $10.00 or more
- Charges a monthly fee for no more than $1.00
- Pay interest on all account balance of $10.00 or more

* 4. I certify that my financial institution has a qualified Basic Banking for Massachusetts Checking Account ONLY. This means the account meets all of the following criteria.

Basic Banking Checking Account Guidelines:
- Requires no more than $25.00 to open the account
- Charges a monthly fee of no more than $3.00
- Provides at least 15 free withdrawals, including at least eight (8) checks, per month
- Charges no more than $1.00 for each withdrawal over the allowable number of free withdrawals

* 5. I certify that my financial institution has a qualified Basic Banking for Massachusetts Savings Account ONLY. This means the account meets all of the following criteria.

Basic Banking Savings Account Guidelines:
- Requires no more than $10.00 to open an account
- Charges no monthly fee on account balances of $10.00 or more
- Charges a monthly fee for no more than $1.00
- Pay interest on all account balance of $10.00 or more

* 6. Our financial institution does NOT have any qualified Basic Banking for Massachusetts accounts at this time.

* 7. Please indicate the name and contact information for the person to whom we should address Basic Banking correspondence.

* 8. Please provide the name and contact information for an additional contact, if applicable.

Thank you so very much for participating in this *green* alternative to a paper mailing!

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