Gredit Application

Gredit Application
lmportant lnformation to Applicant(s). 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 applies for a loan or opens an account.
What this means for you. When you apply for a loan or 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. ln some instances,
we may use outside sources to confirm the information. The information
you provide is protected by our privacy policy and federal larv.
Read each instruction carcfully beforc completing this form.
le
Crcditor
("You" means Applicant, et a/; and "We" means Creditor)
Account No.
Date Received
Class No.
1. Tvpe of Application
Check only one of the three types:
tr lndividual Credit - You are relying g!g!y on your income or assets.
tr
tr
lndividual Credit - You are relying on your income or assets as well
as income or assets from other sources.
Joint Credit - By initialing below, you intend to apply for " joint credit"
Ioint
>plicant
Ap-tiiaant
2. Tvpe of Requesed Credit
Application Date
Amount
No. of Months
Financing Type
tr
tr
tr
$
tr
Refinance
tr
Modification
Proceeds of Crcdit
tr
tr
tr
tr
tr Agricultural
tr Business
E Consumer
Line of Credit
Loan
Sale
Lease
U
tr
!
tr
E
Unsecured
Secured
D
Gov't lD No.
Gov't lD lssued
Gov't lD lssue Date
Gov't lD Erp. Date
Date of Brth
Soc. Sec. No.
Primary Phone
tr
Cbll
Second
Phone
S
tr
Cell
Addrcss
PreviousAddrcss
Gov't lD Type
Gov't lD No.
Gov't lD lssued
Gov't lD lssue Date
Gov't lD E(p. Date
Date of Brth
Soc. Sec. No.
Primary Phone
tr Oivn tr Rent tr
No. of Yrs.:
Present
! Orvn tr Rent !
No. of Yrs.:
PreviousAddress
Dependents No.:
Address
tr
CEll
Second
$
Phone
tr
Cell
Name:
Name:
Address:
!
Telephone:
Cell
Your Relationship to us (or our affiliate)
Enployee
tr
when:
officdbranch:
Klws Finacid Ssvi6
! Oryn tr Rent tr
No. of Yrs.:
Aoes:
Telephone:
tr
Cell
D Yes n
No
tr None tr Enployee !
lnsider (Shareholder, Director, Officer)
Have you ever received crcdit from
lf yes,
when:
us?
! Yes tr
No
officdbranch:
vMrcl48 (1211).00
Univssd Credit Applic€tion
VMP(O Barkss SystflsTM
No. of Yrs.:
Your Relationship to us (or our affiliate)
lnsider (Shareholder, Director, Officer)
us?
tr Rent tr
Oryn
Nearest Relative (not living with you)
Address:
Have you ever received credit from
D
Dependents No.:
Aqes:
Nearest Relative (not living with you)
Woltqs
Joint Applicant or Other Party
Email Address:
Email Address:
lf yes,
to Be Used for
To purchase property that will secure your credit
To purchase property that is a residential dwelling and is not real estde
To finance home improvements to a residential dwelling
Cther (describe):
Full Name (Hrst, Middle, Last)
Gov't lD Type
tr None tr
First Payment Date
Monthly
3. Apolicant lnformation
Applicant
Full Name (First, Middle, Last)
Present
Repayment lnterval
Nory
O '1986, 2012
ucA
11t112012
Page 1 of 4
lf the "Joint Applicant" or "Aher
the Joint Applicant or Othu
My"
4. Asset and Debt lnformation
Secfrbns were completd, this Sectlon should be
tuty, if qplic&le.
compbtd by giving information about both the Applicant, and
Assets Owned
Iype of Asset or
Current Market Value
Remaining Balance of Lien
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
[] Amounts from
Continuation Form
$
$
Total Assets
$
$
Descriotion
Account Number
Outstandinq DebtS (Inrs
Creditor Name
Landlord
section should be charge accounts, installment
Type of Debt, or
Account Number
tr Rent llayment
tr
Mortgage
Original Amount
(hter "0" if none)
contrets, crdit cards, rent, mottgages and other obligations.)
fresent
Monthly
Debtor's Name
Elalance
Pavment
Pa,st Due
(Yes/ltkt)
$
$
a
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Q
$
$
$
$
$
$
Q
$
$
$
$
$
E Amounts from
Continuation Form
$
$
$
Total Debts
$
$
$
Credit References - Name
Asset Owne/s Name
Original Amount Borrowed
Date l%id in Full
$
$
$
vMrc148 (1211).00
Univetsl Credit Applicdion
VMP@) Barkss SystffisTM
Woltss
Klws Finacid Ssvic6
(q)
1986, 2012
ucA
11t112012
P4,e2ot 4
Applicant
1st Employer: fl
Current E Previous tr Self
5. Emolovment lnformation
No. of Yrs.:
1st Employer:
Name:
Name:
Address:
Address:
Mgr.:
Mgr.:
Phone:
E Current E Previous ! Self
No. of Yrs.:
2nd Enployer
Name:
Name:
Address:
Address:
Mgr.:
E Current E Previous tr Self
No. of Yrs.:
Phone:
Gross Monthly Salary/Comm.: $
Fosition/Title:
D Current fl Previous tr Self
No. of Yrs.:
3rd Employer:
Name:
Name:
Address:
Address:
Mgr.:
Phone.
Mgr.:
Phone:
Gross Monthly Salary/Comm.: $
Fosition/Title:
3rd Employer:
Joint Applicant or Other Pafty
Previous tr Self No. of Yrs.:
Gross Monthly Salary/Comm.: $
Fosition/Title:
Gross Monthly Salary/Comm.: $
Fosition/Title:
znd Fnployer:
E Current tr
E Current E Previous tr Self
Mgr.:
Phone:
No. of Yrs.:
Phone:
Gross Monthly Salary/Comm.: $
Fosition/Title:
Gross Monthly Salary/Comm.: $
Fosition/Title:
Joint Applicant or Other Party
Applicant
6. Other lncome
Alimony, child support, or separate maintenance income need not be
Alimony, child support, or separate maintenance income nee.d not be
revealed if you do not wish to have it considered as a basis for rcpaying revealed if you do not wish to have it considered as a basis for repaying
thb obligation.
this obligation.
Alimony, child support, separate maintenance received under:
tr Court order tr Written agreernent ! Oral understanding
Alimony, child support, separate maintenance received under:
D Court order ! Written agreement tr Oral understanding
$
$
per Month
reduced beforc the I ls any income listed in Sections 4, 5 or 6 likely to be rcduced before the
credit is paid off:
Z Ya (&platn in s*tion 10.) tr No
ls any income listed in
credit is paid off:
J Y*
per Month
Source:
Source:
(&plain in setion 10.)
7. Other Obliqations
Applicant
D Yes tr No
lf yes,
Amount: $
Are you a co-maker, endorser, co.signer, surety, or
guarantor on any loan, contract or other obligation?
Joirrt Applicant or Otlrer Party
lf yes,
Amount: $
tr Yes D No
For whom:
To whom:
For whom:
To whom:
Amount per month: $
! Yes D No lf yes,
Amount per month: $
To whom:
To whom:
tr Yes ! No
tr Yes tr No
there any unsatisfied judgments against you?
lf yes,
lf yes,
Have you been declared bankrupt in the last 10 years?
! Yes ! No
n Yes tr No
lf yes,
Where:
Year:
Where:
Year:
lf yes,
Amount per month: $
Are you obligated to make Alimony, Support or
Maintenance l*lyments?
To whom:
! Yes tr No lf yes,
Amount per month: $
To whom:
8. Propeftv lnformation (if secured)
Property Type
tr Boat or Vessel
Certificate of Deposit
tr Deposit Account
D Manufactured Home
tr Motor Vehicle
Property Description
Property Location and Address
n
tr
Pnmary use or Propeny
tr Agricultural
D
tr Residential Drvelling ! Homestead Property
Property Owne(s) Names & Addresses
Business
f] Consumer
Univetsal Credil Apphcdion
VMP'D Bankss SyslflsrM
Woltss
Klws Frnacid Sqvic
vMrcl48 (1211).00
O 1986, 2012
ucA
11t112012
Page 3 of 4
9. MaritalStatus
Applicant
Leave blank, unless:
Joint Applicant or Other Partv
Leave blank, unless:
) the credit will be secured, or
(2) you reside in a community property state, or
(3) you are relying on propefty, located in a community propefty
(1) the credit will be
secured, or
(2) you reside in a community propefty state, or
(3) you are relying on propetty, located in a community propefty
(1
sfafq as a basls for repayment.
state, as a basls for repayment.
Married (as defined by state law; incl. domestic padnership, civil union)
Married (as defind by state law; incl. domestic partnership, civit union)
Separated
Separated
Unmarried (including single, divorcd,
w
idowd)
Unmarried (including single, divorcd,
wi&wd)
10. Additional lnformation or Exolanations
11
. Notices
Califomia Residents. Each applicant, if married, may apply for a separate account.
New York Residents. A consumer report may be ordered in connection with your applicdion. Upon your request, we will inform you whether or
not a report was ordered. lf a report was ordered, we will tell you the name and address of the consumer reporting agency that provided the
report. Subsequent reports may be ordered or utilized in connection with an update, rensral or extension of credit foi which you have applied.
Ohio Residents. The Ohio larvs against discrimination require all creditors make credit equally available to all creditworthy customers, and that
credit reporting agencies maintain separate credit histories on each individual upon request. The Ohio Civil Rights Commission administers
compliance with this lan.
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim
containing a false or deceptive staternent is guilty of insurance fraud.
Texas Residents. The owner of the homestead is not required to apply the proceeds of the extension of credit to repay another debt except debt
secured by the homested or debt to another lender.
Wisconsin Residents. Notice to Married Applicants. No provision of any marital property agreement, unilateral statement under Wisc. Statutes
S 766.59 or a court decree under Wsc. Statutes S 766.70 adversely affects the interests of the Creditor unless the Creditor, prior to the time the
credit is granted, is furnished a copy of the 4reement, staternent or decree or has actual knowledge of the adverse provision when the obligation
to the Creditor is incurred.
For Married Wsconsin Residents. The credit being applied for, if granted, will be incurred in the interest of my marriage or family. I understand
the Creditor may be required by larv to give notice of this transaction to my spouse.
1
2.
Certif ications, Authorizations and Signatures
You certify that everything you have stated in this Credit Application and on any other documents submitted to us are true and corr@t to the best
of your knowledge. You understand that you must update the information contained in this Credit Application if either your financial condition
materially changes or we make a request to you orally or in writing. You understand that we will retain this Credit Application whether or not it is
approved.
You authorize us to request one or more consumer reports, to check and verify your credit and employment history, and to answer questions
others may ask us about our credit experience with you.
You authorize us to contac.t you using any of the telephone numbers listed on this Credit Application or that you subsequently provide us in
conneclion with your.credit account - regardless whether the number we use is assigned to a paging service, cellular telephohe service,
specialized mobile radio service, other radio common carrier service or any other service for which ybu may be charged for the call. You further
authorize us to contact you through the use of voice, text and email and through the use of prereccirded/artificial voi-ce messages or an automatic
dialing device.
tr Electronic Signature. lf checked, You further agree that you have signed this Aedit Application with one or more electronic signatures. You
intend your electronic signature to have the effect of your written ink signature. You vianved and read the entire Oedit Application and notices
before you signed it. You received a pgper copy of this Gedlt Application atter it was signed. You understand that this Credit Applicatlon is in
the electronic form that we will keep. We may rely on, and enforce, this Credlt Application in the electronic form or as a paper veision of the
electronic form.
Applicant Signature
Date
Joint Applicant, or Other Party, Signature
Date
(if applicable)
Notice: lt is a federal crime punishable.by fine, impriso_nment,-or boJh, tg knowingly make any false statements concerning any of the above facts
as applicable under the provisions of Title 18, United States Code S 1001 , ef seg.
M
ortgage loan Originator lnformation
lf this &edlf Application is secured by a consumer's residential dwelling that is owned by you, we may be required under federal or state law to
disclo,se ou-r mortgage loal origination identification.number(s), which are as follows, if applicable:
a
a
Mortgage Loan Originator Name and ldentifier:
Mortgage Loan Origination Company Name and ldentifier:
For Creditor Use
Date Received
Received
Unive[Sd Credit Applicdim
VMP(D Barkss Syde.nsTM
\ /ottss Klws Finacid
Ssvic
$
Date Action Taken
Action Taken
S
Action Taken
Reason Code(s)
vMrc148 (1211).00
O 1986, 2012
ucA
1111120',12
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