APPLICANT

CO-APPLICANT               CO-SIGNER

APPLICANT NAME (LAST, FIRST, MIDDLE)

CO-APPLICANT NAME (LAST, FIRST, MIDDLE)

HOME PHONE NO.

HOME COUNTY

HOME PHONE NO.

HOME COUNTY

SOCIAL SECURITY NO.

DRIVER’S LIC.  NO                 STATE

SOCIAL SECURITY NO.

DRIVER’S LIC.  NO       STATE

BIRTH DATE

NUMBER & AGES OF DEPENDENTS

BIRTH DATE

RELATIONSHIP TO APPLICANT

HOME ADDRESS (STREET & NO.)         

HOW LONG (years)

HOME ADDRESS (STREET & NO.)

HOW LONG (years)

HOME ADDRESS (CITY, STATE, ZIP)

HOME ADDRESS (CITY, STATE, ZIP)

PREVIOUS HOME ADDRESS (STREET, CITY, STATE, ZIP)

EMPLOYER

START DATE

EMPLOYER

START DATE

WORK ADDRESS (STREET & NO.)

WORK ADDRESS (STREET, CITY, STATE, ZIP)

WORK ADDRESS (CITY, STATE, ZIP)

WORK PHONE NUMBER

CURRENT POSITION

WORK PHONE NUMBER

CURRENT POSITION

CURRENT GROSS ANNUAL  PAY  $

CURRENT GROSS MONTHLY 

PAY $

CURRENT GROSS ANNUAL PAY $

CURRENT GROSS MONTHLY PAY$

OTHER MON. INCOME  (EXCLUDE ALIMONY, CHILD SUPPORT, MAINTENANCE PAYMENT)

$____________________________SOURCE_________________________

$____________________________SOURCE_________________________

OTHER MON. INCOME  (EXCLUDE ALIMONY, CHILD SUPPORT, MAINTENANCE PAYMENT)

$____________________________SOURCE_________________________

$____________________________SOURCE_________________________

YOU ARE NOT REQUIRED TO DISCLOSE INCOME FROM ALIMONY.  CHILD SUPPORT OR SEPARATE MAINTENANCE PAYMENTS, BUT IF YOU WANT IT CONSIDERED WITH THIS APPLICATION, COMPLETE THE FOLLOWING:

          ALIMONY        CHILD SUPPORT          MAINTENANCE          ARE PAYMENTS UP TO DATE            YES           NO

MONTHLY $_________________________PAYOR_________________________HOW LONG HAVE PAYMENTS BEEN MADE?________________

NAME & ADDRESS OF NEAREST RELATIVE  
(Not living with you)

NAME & ADDRESS OF OTHER REFERENCE

RELATIONSHIP

PHONE NUMBER

RELATIONSHIP

PHONE NUMBER

DEBTS: THE FOLLOWING IS A TRUE AND COMPLETE STATEMENT OF ALL OF MY/OUR DEBTS (INCLUDING THOSE FOR WHICH I/WE ARE OBLIGATED AS CO-SIGNER, ENDORSER, OR GUARANTOR) AND IS GIVEN FOR THE PURPOSE OF OBTAINING CREDIT.

LIST ALL AMOUNTS OWED.  ATTACH ADDITIONAL SHEET IF NECESSARY.  FAILURE TO LIST ALL OBLIGATIONS MAY RESULT IN REJECTION.  IF YOU HAVE NO DEBTS, PRINT THE WORD ‘NONE.’            ADDITIONAL LISTING OF DEBTS IS ATTACHED.

ENTER APPROPRIATE CODE FOR EACH ENTRY              CODES:

1. MORTGAGE             3. HOME EQUITY LOANS          5. RENT OR LOT RENT           7. AUTO OR TRUCK LOAN

          2. 2^ND MORTGAGE      4. HOME ASSOC. DUES             6.  CREDIT CARD                      8. CO-SIGNER               9. OTHER

CODE

CREDITOR NAME

ACCOUNT NUMBER

INTEREST RATE

CREDIT LIMIT

BALANCE OWED

MINIMUM PAYMENT

DELINQUENT AMOUNT

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

ALIMONY, CHILD SUPPORT, MAINTENANCE

$

$

$

ESTIMATED MARKET VALUE OF HOME

$

MAKE & YEAR OF AUTO 1

MAKE & YEAR OF AUTO 2

HAVE YOU EVER DECLARED BANKRUPTCY?

            NO         YES            WHEN?         

ARE YOU A UNITED STATES CITIZEN OR RESIDENT ALIEN?

             NO              YES

ARE YOU PRESENTLY A PARTY IN A LAW SUIT?

            NO         YES

ARE YOU A CO-SIGNER ON ANY OTHER LOAN?

             NO              YES

DO YOU HAVE A CHECKING ACCOUNT AT ANOTHER FINANCIAL INSTITUTION?

            NO         YES            NAME OF INSTITUTION                                                              ACCOUNT NUMBER

SIGN HERE:   All the information in this application is true.  The Credit Union is relying on what I/We stated in this application and I/We acknowledge that everything I/We have stated is true and correct and that I/We have provided a COMPLETE listing of all my our debts and obligations.  I/We authorize the Credit Union  to investigate any facts, verifying employment information and obtain and exchange reports with credit reporting agencies and others regarding this application and any renewals, updates or extensions of any new credit extended as a result of this application.  Upon request, I/We will be informed of each agency’s name and address.  I/We have read this entire application, agree to its terms and understand that I/We will be jointly and severally liable for repayment of the entire debt.  If this application is approved, I/We agree to honor the provisions of the credit and security agreements covering the loan or account.

Signature of Applicant                             Date

X

Credit union use only          D/l Ratio

Amount Approved $    _________________________________

Signature of Co-Applicant                       Date

X

                     Approved                         Rejected

Credit Committee or Loan Officer

__________________________________________________________

Amount Requested $_________________________________