Consumer Loan Application

Amount Requested
$
Length of Loan/Pymt Date Desired
Proceeds to be Used for
Collateral Offered
Check One:    Secured Credit     Unsecured Credit     Individual     ****Joint
  ***We intend to apply for joint credit     (all borrowers initial here)
Marital Status
 Married (you may apply for separate or joint credit)
 Separated
Unmarried (includes single, divorced, and widowed) List the number of people dependent on you for financial support:

Applicant Information
Name
Social Security Number
DOB
E-mail
Street Address
City
Country
State
Zip
Time At Present Address
Yrs:  Mos:
Home Phone
Cell Phone
Live with:  Own
 Rent
 Parents
 Other
Name & Phone of friend/relative not living with you
Previous Street Address (if less than 2 years current)
City
Country
State
Zip
Time At Present Address
Yrs:  Mos:
Employer's Name
Address
City
Type of Business
Position/Title
Work E-mail
Work Phone
Time There
Yrs:  Mos:
Gross Monthly Income
Do you intend to rely on spouse's
earnings to qualify for this loan?
 Yes  No Other Income
$per month
Source:
If yes, your spouse also may be required to sign the promissory note Note: Alimony, Child Support or Separate Maintenance Incomes do not have to be revealed unless you wish to have them considered in loan qualification.
Previous Employer (if less than 3 years at current)
Address
Phone
Position
Time There
Yrs: Mos:
Co-Applicant Information
Name
Social Security Number
DOB
E-mail
Street Address
City
Country
State
Zip
Time At Present Address
Yrs:  Mos:
Home Phone
Cell Phone
Live with:  Own
 Rent
 Parents
 Other
Name & Phone of friend/relative not living with you
Previous Street Address (if less than 2 years current)
City
Country
State
Zip
Time At Present Address
Yrs:  Mos:
Employer's Name
Address
City
Type of Business
Position/Title
Work E-mail
Work Phone
Time There
Yrs:  Mos:
Gross Monthly Income
Do you intend to rely on spouse's
earnings to qualify for this loan?
 Yes  No Other Income
$per month
Source:
If yes, your spouse also may be required to sign the promissory note Note: Alimony, Child Support or Separate Maintenance Incomes do not have to be revealed unless you wish to have them considered in loan qualification.
Previous Employer (if less than 3 years at current)
Address
Phone
Position
Time There
Yrs: Mos:
Home Information
 Rent   Own First Mortgage Holder or Landlord Address
Purchase Date/House
Purchase Price
Estimated Current Value
Balance Owing
Mortgage No.
Monthly Payment/Rent

Assets   Value
Checking Cash $
Savings & Certificates $
Life Insurance (cash value) $
Stocks and Bonds $
Retirement Accounts $
Home Market Value $
Vehicles $
Boats $
Snowmobiles $
Four Wheelers $
Other Assets $
  $
Total Assets $

List all debts, including second mortgage.  Attach separate sheet if needed.
Name of Lender
Address
Account No.
Original Amount
Balance
Mo. Payment
 
Have you or your Co-Applicant ever:  
Declared Bankruptcy?  Yes   No  Had a Judgment?  Yes   No Had a repossession or foreclosure?  Yes   No
Are you a Co-Maker, Endorser, or Guarantor on any Loan or Contract?  Yes   No 
If yes, please Explain:
 
 
Automatic Loan Payment  
Do you want your monthly payment automatically deducted from your checking or savings account?
Yes, Account # No  
Automatically transferred funds will be applied as my monthly payment on each monthly due date so long as there are adequate funds on deposit or there is available credit in my account, until the loan is paid or the Bank receives written notice to cancel. I understand the Bank reserves the right to terminate the automatic repayment plan without notice.
Please initial your request.
Agreement/Signature  
Everything that I/We have stated in this application and on any attachments is correct to the best of my/our knowledge. I understand that Pine Island Bank will retain this application whether or not it is approved and Pine Island Bank is authorized to check my credit and employment history and to answer questions others may ask Pine Island Bank about my credit record with Lender. I understand that I must update credit information at Pine Island Bank's request if my financial condition changes. A person supplying a false material statement that is believed not to be true with respect to information requested on the application form is guilty of perjury. MS 48.512, Subd 2
X: X:
  Applicant Signature Date   Co-Applicant Signature. (Co-Applicant should sign only if applying for a joint credit) Date