online application

Email address:
Amount: $
Purpose of Loan:

1. BORROWER INFORMATION
Borrower Co Borrower
Name (include Jr. or Sr. if applicable) Name (include Jr. or Sr. if applicable)
Soc. Sec. Nbr.
 Home Phone
 Soc. Sec. Nbr.
 Home Phone
Age Yrs. of School Age Yrs. of School
Birth Date: e.g. 01/01/1970 Birth Date: e.g.01/01/1973
Marital Status Married Unmarried Separated Dependents No. Ages Marital Status Married Unmarried Separated Addl Dependents No. Ages
Present Address: Present Address:
Street Street
City City
State Zip State Zip
Own
Rent		 No. Yrs.
 Own
Rent		 No. Yrs.
IF AT PRESENT ADDRESS LESS THAN TWO YEARS …
Former Address: Former Address:
Street Street
City City
State Zip State Zip
Own
Rent		 No. Yrs.
 Own
Rent		 No. Yrs.


2. EMPLOYMENT INFORMATION

Borrower Co Borrower
Name of Employer: Name of Employer:
Address:
 Address:
City:
 City:
State:
 Zip:
 State:
 Zip:
Self-employed Yes No Years on this job: Self-employed Yes No Years on this job:
Yrs. in current profession:
 Yrs. in current profession:
Position/Title/Type of Bus: Position/Title/Type of Bus:
Business Phone:
 Business Phone:
IF EMPLOYED IN CURRENT POSITION FOR LESS THAN TWO YEARS…
Name of Employer: Name of Employer:
Attn:
 Attn:
Address:
 Address:
City:
 City:
State:
 Zip:
 State:
 Zip:
Self-employed Yes
No		 From:
Yr:

To:
Yr:

Self-employed Yes
No		 From:
Yr:

To:
Yr:

Monthly Income:$
 Monthly Income:$
Position/Title/Type of Bus: Position/Title/Type of Bus:
Business Phone:
 Business Phone:


3. MONTHLY INCOME AND COMBINED HOUSING EXPENSE INFORMATION

Gross Mo. Income Borrower Co-Borrower
Base Empl. Income* $
 $
Overtime $
 $
Bonuses $
 $
Commissions $
 $
Dividends/Interest $
 $
Net Rental Income $
 $
Other** $
 $
Total $
 $

* Self Employed Borrower(s) may be required to provide additional
documentation such as tax returns and financial statements.

Combined Monthly Housing Expenses Present Proposed
Rent $ $
First Mortgage (P&I) $ $
Other Financing (P&I) $ $
Hazard Insurance $ $
Real Estate Taxes $ $
Mortgage Insurance $ $
Homeowner Assoc. Dues $ $
Other $ $
Total $ $

4. ASSETS AND LIABILITIES

This statement and any applicable supporting schedules
may be completed jointly by both married and unmarried Co-borrowers if their assets and
liabilities are sufficiently joined so that the Statement can be meaningfully and fairly
presented on a combined basis; otherwise separate Statements and Schedules are required.
If the Co-Borrower section was completed about a spouse, this Statement and supporting
schedules must be completes about that spouse also.

Completed:

Jointly

Not JointlyASSETSName & Address of Bank, S&L, or Credit Union:

Acct. no.

Cash or Market Value: $
LIABILITIES

TotalMonthly Payments $