Overdraft Protection

 Amount of credit desired  Checking account number
   
Type of Application
Individual credit
Joint credit with spouse
Joint credit with

Section A - Individual Applicant Information

Name
(First, Middle, Last)
Birth
Date
Telephone
Number
Email Address Cell Phone
Number
   
Driver's
License No
Social Security
Number
Number of
Dependents
Ages of
Dependents
Address
(Street, City, State, & ZIP)
County Do you
Own or Rent
How Long
Previous Address (Street, City, State, & ZIP) (Complete if less than 3 yrs at current address)
  County Did you
Own or Rent
How Long
Employer
(Company Name & Address)
How Long
Business Phone Position or
Title
Salary / Month
Gross $
Net $
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? Have you previously received credit from us?
No Yes (Explain) No Yes (When)
Name & address of nearest relative not living with you Relationship   Telephone
 

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.

Name
(First, Middle, Last)
Birth
Date
Telephone
Number
Email Address Cell Phone
Number
   
Driver's
License No
Social Security
Number
Number of
Dependents
Ages of
Dependents
Address
(Street, City, State, & ZIP)
County Do you
Own or Rent
How Long
Previous Address (Street, City, State, & ZIP) (Complete if less than 3 yrs at current address)
  County Did you
Own or Rent
How Long
Employer
(Company Name & Address)
How Long
Business Phone Position or
Title
Salary / Month
Gross $
Net $
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? Have you previously received credit from us?
No Yes (Explain) No Yes (When)
Name & address of nearest relative not living with you Relationship   Telephone
 

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 (includes single, divorced and widowed)
Other Party 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

(Use a separate sheet if necessary.)

Description of Assets Name in Which the
Account is Carried
Subject
to Debt?
Value
Checking Account Number(s)
Name of Financial Institution
$
Savings Account Number(s)
Name of Financial Institution
 
Certificate of Deposit Account Numer(s)
Name of Financial Institution
 
Marketable Securities - Issuer
Type, no. of shares
 
Real Estate (homestead, rental, other)
Address
 
Life Insurance - Issuer
Face value
 
Automobile - Make
Model, year
 
Other

 
Total Assets       $

Outstanding Debts

(Include charge accounts, installment contracts, credit cards, rent, mortgages and other obligations.  Use separate sheet if necessary.)

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
     
     
     
     
     
Total Debts     $ $ $

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? No Yes
If yes, to (Name & Address) Amt. per month $
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 judgments 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?
Notice to Married Applicants: No provision of any marital property agreement, unilateral statement under Wisc. Statutes §766.59 or a court decree under Wisc. Statutes §766.70 adversely affects the interest of the creditor unless the creditor, prior to the time the credit is granted, is furnished a copy of the agreement, statement or decree or has actual knowledge of the adverse provision when the obligation to the creditor is incurred.

Section E - Secured Credit

Complete only if credit is to be secured.  Briefly describe the property to be given as security:

Property Description
Names & Addresses of All Co-Owners of the Property
If the security is real estate, give the full name of your spouse (if any)

Important Disclosure for Personal Reserve Account Applications

I agree that I have read and agree to the following product Disclosures, Agreements, and Terms & Conditions:

I Agree PRA Online Disclosure

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 I must update credit information at Lender's request if my financial condition changes.

Applicant's Signature Date Other Signature (Where Applicable) Date