Consumer Application Insurance Disclosure

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Credit Application
Important Information 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. In some instances, we may use outside sources to confirm the information. The information you provide is protected by our privacy policy and federal law.
Read each instruction carefully before completing this form.
For Creditor Use
1. Type of Application
Creditor
(“You” means Applicant, et al; and “We” means Creditor)
Individual Credit – You are relying solely on your income or assets.Individual 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”.
2. Type of Requested Credit
NewRefinanceModification
MonthlyOther
Line of CreditLoanSaleLease
AgriculturalBusinessConsumer
UnsecuredSecured
To purchase property that will secure your creditTo purchase property that is a residential dwelling and is not real estateTo finance home improvements to a residential dwellingOther
3a. Applicant Information
OwnRent
OwnedRented
NoneEmployeeInsider (Shareholder, Director, Officer)
YesNo
3b. Joint Applicant / Other Party Information
OwnRent
OwnedRented
NoneEmployeeInsider (Shareholder, Director, Officer)
YesNo
4. Asset and Debt Information
If the “Joint Applicant” or “Other Party” Sections were completed, this Section should be completed by giving information about both the Applicant, and the Joint Applicant or Other
Party, if applicable.

ASSETS OWNED
N/A
N/A
N/A
N/A
Outstanding Debts (This section should be charge accounts, installment contracts, credit cards, rent, mortgages and other obligations.)
Creditor Name
Type of Debt/Account
Original Amount
Present Balance
Monthly Payment
Debtor’s Name
Past Due (Y/N)
Yes
N/A
N/A
Yes
N/A
N/A
N/A
N/A
N/A
N/A
Credit References – Name
Original Amount Borrowed
Date Paid in Full
5a. Applicant Employment Information
5b. Joint Applicant / Other Party Employment Information
6a. Applicant Other Income
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.
Court orderWritten agreementOral understanding
Yes (Explain in section 10.)No
6b. Joint Applicant / Other Party Other Income
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.
Court orderWritten agreementOral understanding
Yes (Explain in section 10.)No
7a. Applicant Other Obligations
YesNew Option
YesNo
YesNo
YesNo
7b. Joint Applicant / Other Party Other Obligations
YesNo
YesNo
YesNo
YesNo
8. Property Information (if secured)
Boat or VesselCertificate of DepositDeposit AccountManufactured HomeMotor VehicleOther
AgriculturalBusinessConsumer
Residential DwellingHomestead Property
9a. Applicant Marital Status
Leave blank, unless:
(1) the credit will be secured, or
(2) you reside in a community property state, or
(3) you are relying on property, located in a community property state, as a basis for repayment.
MarriedSeparatedUnmarried (including single, divorced, widowed)
9b. Joint Applicant / Other Party Marital Status
Leave blank, unless:
(1) the credit will be secured, or
(2) you reside in a community property state, or
(3) you are relying on property, located in a community property state, as a basis for repayment.
MarriedSeparatedUnmarried (including single, divorced, widowed)
10. Additional Information or Explanations
11. Notices
California Residents. Each applicant, if married, may apply for a separate account.
New York Residents. A consumer report may be ordered in connection with your application. Upon your request, we will inform you whether or not a report was ordered. If 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, renewal or extension of credit for which you have applied.
Ohio Residents. The Ohio laws 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 law.
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 statement 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 homestead or debt to another lender.
Wisconsin Residents. 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 interests 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.
For Married Wisconsin 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 law to give notice of this transaction to my spouse.
12. Certifications, 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 correct 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 contact you using any of the telephone numbers listed on this Credit Application or that you subsequently provide us in connection with your credit account – regardless whether the number we use is assigned to a paging service, cellular telephone service, specialized mobile radio service, other radio common carrier service or any other service for which you 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 prerecorded/artificial voice messages or an automatic dialing device.
If checked, You further agree that you have signed this Credit Application with one or more electronic signatures. You intend your electronic signature to have the effect of your written ink signature. You viewed and read the entire Credit Application and notices before you signed it. You received a paper copy of this Credit Application after it was signed. You understand that this Credit Application is in the electronic form that we will keep. We may rely on, and enforce, this Credit Application in the electronic form or as a paper version of the electronic form.
Mortgage Loan Originator Information
If this Credit Application is secured by a consumer’s residential dwelling that is owned by you, we may be required under federal or state law to disclose our
mortgage loan origination identification number(s), which are as follows, if applicable:
For Creditor Use
FEDERAL CREDIT APPLICATION INSURANCE DISCLOSURE
I have applied for an extension of credit with you. You are soliciting, offering, or selling me an insurance product or annuity in connection with this extension of credit. FEDERAL LAW PROHIBITS YOU FROM CONDITIONING THE EXTENSION OF CREDIT ON EITHER:

My purchase of an insurance product or annuity from you or from any of your affiliates; or
My agreement not to obtain, or a prohibition on me from obtaining, an insurance product or annuity from an unaffiliated entity.

By signing, I acknowledge that I have received a copy of this form on today's date. Unless this disclosure is provided electronically or I have applied for credit by mail, I also acknowledge that you have provided this disclosure to me orally.


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