Loan Application

Important Applicant Information: Federal law requires financial institutions to obtain sufficient information to verify your identity. You may be asked several questions and to provide one or more forms of identification to fulfill this requirement. In some instances we may use outside sources to confirm the information. The information you provide is protected by our privacy policy and federal law.

An asterisk (*) denotes a required field.

Type of Credit Requested

Important: Please check the appropriate boxes below and complete the applicable sections.*

Individual Credit - relying solely on my income or assets
Individual Credit - relying on my income or assets as well as income or assets from other sources
Joint Credit - we intend to apply for joint credit   (initials)
Secured
Unsecured

Amount Requested *
$
For How Long *
Payment Date Desired
Want to Repay
Monthly Other
Proceeds of loan used for: *

Section A - Individual Applicant Information

Name (Last, First, Middle) *
Birth Date *
Telephone Number *
Driver's License Number *
Driver's License State Issued *
Driver's License Date of Issuance *
Driver's License Expiration Date *
Social Security Number *
Number of Dependents *
Ages of Dependents
Address (Street, City, State, and Zip) *
County
Do you currently
own or rent?
How Long?
Previous Address (Street, City, State, and Zip) (Complete if less than 3 years at present address)

County
Did you
own or rent?
How Long?
Employer (Company Name and Address) *
How Long? *
Business Phone and Ext.
Position or Title
Gross Salary per Month *
$
Net Salary per Month *
$
Previous Employer (Company Name and Address)
How Long?
Name and Address of Nearest Relative Not Living with You
Relationship
Telephone # (include area code)
Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis of repaying this obligation.

Alimony, child support, separate maintenance received under:
Court Order Written Agreement Oral Understanding
Sources of Other Income
Amount per Month
$
Is any income listed in this Section likely to be reduced before the credit request is paid off? *
No Yes (Please explain)
Have you previously received credit from us? *
No Yes - When?

Section B - Joint Applicant or Other Party Information

Complete only if: for joint credit, for individual credit relying on income or assets from other sources, or applicant is married and resides in a community property state.

Please check this box if there is a joint applicant

Name (Last, First, Middle)
Birth Date
Telephone Number
Driver's License Number
Driver's License State Issued
Driver's License Date of Issuance
Driver's License Expiration Date
Social Security Number
Number of Dependents
Ages of Dependents
Relationship to Applicant (if any)
Address (Street, City, State, and Zip)
How Long?
Employer (Company Name and Address)
How Long?
Business Phone and Ext.
Position or Title
Gross Salary per Month
$
Net Salary per Month
$
Previous Employer (Company Name and Address)
How Long?
Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis of repaying this obligation.

Alimony, child support, separate maintenance received under:
Court Order Written Agreement Oral Understanding
Sources of Other Income
Amount per Month
$
Is any income listed in this Section likely to be reduced before the credit request is paid off?
No Yes (Please explain)
Has Joint Applicant or Other Party ever received credit from us?
No Yes - When?

Section C - Marital Status

Complete ONLY if: for joint or secured credit, or applicant resides in a community property state or is relying on property located in such a state as a basis for repayment of the credit requested.

Applicant * Married Separated Unmarried (including single, divorced, and widowed)
Other Party Married Separated Unmarried (including single, divorced, and widowed)

Section D - Asset and Debt Information

If Section B has been completed, this Section should be completed giving information about both the Applicant and Joint Applicant or Other Person. Please mark Applicant-related information with an "A". If Section B was not completed, only give information about the Applicant in this Section.

Assets Owned
Description of Assets Name in Which the
Account is Carried
Subject to
Debt?
Value
Checking Account Number(s)
(where)
No
Yes
$
Savings Account Number(s)
(where)
No
Yes
$
Certificate(s) of Deposit
(where)
No
Yes
$
Marketable Securities
(issuer, type, # of shares)
No
Yes
$
Real Estate
(location, date acquired)
No
Yes
$
Life Insurance
(issuer, face value)
No
Yes
$
Automobiles
(make, model, year)
No
Yes
$
Other
(list)
No
Yes
$
Total Assets $

 

Outstanding Debts (Including charge accounts, installment contracts, credit cards, rent, mortgages, etc.)
Creditor Account
Number
Name in Which The
Account is Carried
Original
Amount
Present
Balance
Monthly
Payments
Landlord or Mortgage Holder Rent Payment
Mortgage

    (omit rent)
$
    (omit rent)
$

$
Automobiles (describe) $ $ $
Other $ $ $
Other $ $ $
Other $ $ $
Other $ $ $
Other $ $ $
Other $ $ $
Total Debts $ $ $


Complete the following information about both the Applicant and Joint Applicant or Other Person (if applicable):

Are you a co-maker, endorser, or guarantor on any loan or contract? * No Yes If yes, for whom?
To whom?
Are there any unsatisfied judgements against you? * No Yes If yes, to whom owed?
Amount
$
Have you been declared bankrupt in the last 10 years? * No Yes If yes, where?
Year?
Are you obligated to make Alimony, Support or Maintenance Payments? * No Yes If yes, to (Name and Address)
Amount per Month
$

Section E - Secured Credit

Property Description
Names and addresses of all co-owners of the property
If the security is real estate, give the full name of your spouse (if any).

Section F - Notices

Notice to All Applicants. A Consumer Report may be requested in connection with this application for credit or any future update, renewal, or extension of such credit. Upon request, you will be informed whether or not a consumer report was requested. If a report was requested, you will be informed of the name and address of the consumer reporting agency that furnished the report.

Signatures

I certify that everything I have stated in this application and on any attachments is correct. Lender may keep this application whether or not it is approved. By signing below I authorize Lender to check my credit and employment history and to answer questions others may ask Lender about my credit record with Lender. I understand that I must update credit information at Lender's request if my financial condition changes.

Applicant's Signature *
Date *
Other Signature (where applicable)
Date