Consumer Credit Application

Important Information About Opening a New Account:
To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify and record information that identifies each person who opens an account.

What this means for you:
When you open an account, we will ask for your name, address, date of birth and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents.

Type of Application

I intend to apply for

Individual Credit - relying solely on my income or assets Joint Credit - We intend to apply for joint credit

Initials Joint Initials

Type of Credit Requested

Type of Credit Requested Secured Unsecured

Amount Requested Payment Date Desired Proceeds of Loan to Be Used For

Section A - Individual Applicant Information

Name (First, Middle, Last) Phone Number E-mail Address Birth Date Social Security Number Number of Dependents Ages of Dependents Home Address City State Zip Code County

Do you Own Rent

How many years at this address?

Previous Address

Previous Address (Complete if less than 3 yrs at current address) City State Zip Code County How many years at this address?

Employment

Name of Employer Employer's Address City State Zip Code Employer's Phone Number Position or Title How Long Gross Monthly Income

Alimony, child support, separate maintenance

Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for 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 requested is paid off?

Is any income listed in this section likely to be reduced before the credit requested is paid off? Yes No

Explain

References

Name & address of nearest relative not living with you Relationship Telephone

Section B - Joint Applicant or Other Party Information

Name (First, Middle, Last) Phone Number E-mail Address Birth Date Social Security Number Number of Dependents Ages of Dependents Home Address City State Zip Code County

Do you Own Rent

How many years at this address?

Previous Address

Previous Address (Complete if less than 3 yrs at current address) City State Zip Code County How many years at this address?

Employment

Name of Employer Employer's Address City State Zip Code Employer's Phone Number Position or Title How Long Gross Monthly Income

Alimony, child support, separate maintenance

Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for 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 requested is paid off? Yes No

Explain

References

Name & address of nearest relative not living with you Relationship Telephone

Section C - Marital Status

DO NOT COMPLETE MARITAL STATUS SECTION IF THIS IS AN APPLICATION FOR INDIVIDUAL UNSECURED CREDIT.

Applicant Marital Status Married Separated Unmarried (includes single, divorced and widowed)

Other Party Marital Status Married Separated Unmarried (includes single, divorced and widowed)

Section D - Assets & 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

various requested data refer to form label for each entry

Name in Which the Account is Carried

Subject to Debt?

Value

Checking Account Number(s)

Name of Financial Institution

Name in Which the Account is Carried

Subject to Debt

Value

Savings Account Number(s)

Name of Financial Institution

Name in Which the Account is Carried

Subject to Debt

Value

Certificate of Deposit(s)

Name of Financial Institution

Name in Which the Account is Carried

Subject to Debt

Value

Real Estate (homestead, rental, other)

Address

Name in Which the Account is Carried

Subject to Debt

Value

Automobiles - Make

Model, Year

Name in Which the Account is Carried

Subject to Debt

Value

Other

Other Description

Name in Which the Account is Carried

Subject to Debt

Value

Total Assets

Outstanding Debts

(Include charge accounts, installment contracts, credit cards, rent, mortgages and other obligations.)

Creditor

Account Number

Name in Which the Account is Carried

Original Amount

Present Balance

Monthly Payments

Landlord

Name in Which the Account is Carried

Monthly Payment

Mortgage Holder

Account Number

Name in Which the Account is Carried

Original Amount

Present Balance

Monthly Payment

Automobiles (describe)

Account Number

Name in Which the Account is Carried

Original Amount

Present Balance

Monthly Payment

Other

Account Number

Name in Which the Account is Carried

Original Amount

Present Balance

Monthly Payment

Credit Cards

Account Number

Name in Which the Account is Carried

Original Amount

Present Balance

Monthly Payment

Total Debts

Total Debts Original Amount

Total Debts Present Balance

Total Debts Monthly Payments

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

Are you obligated to make Alimony, Support or Maintenance Payments? Yes No

If yes, to (Name & Address) Amount per month $

Are you a co-maker, endorser, or guarantor on any loan or contract? Yes No

If yes, for whom? To whom?

Are there any unsatisfied judgements against you? Yes No

If yes, to whom owed? Amount $

Have you been declared bankrupt in the last 10 years? Yes No

If yes, where? Year?

Signatures

Everything that I have stated in this application is correct to the best of my knowledge. I understand that you will retain this application whether or not it is approved. You are authorized to check my credit and employment history and to answer questions about your credit experience with me.

Applicant's Signature Date

Other Signature Date