Individual Credit: You must complete the Applicant section about yourself and the Other section about your spouse if:
1. you live in or the property pledged as collateral is located in a community property state (AZ, AX, IS, LA, NM, NV, TX, WA, WI),
2. your spouse will use the account, or
3. you are relying on your spouse's income as a basis for repayment. If you are relying on income from alimony, child support, or separate maintenance, complete the Other section to the extent possible about the person on whose payments you are relying.
Joint Credit: If you are applying with another person, complete the Applicant and Other sections.
Guarantor: Complete the Other section if you are a guarantor on an account/loan.
* indicates a field that must be completed before the application can be submitted.
LOANLINER Account/Loan:
(Including ATM/Debit Card Access to the Account if Available)

Amount Requested:*

Purpose/Collateral:*

Repayment:*

Payment
Protection

Single Credit Disability Insurance

 The Credit Union will disclose the cost of disability Insurance for your comparison. A separate insurance election which discloses the terms and conditions must be signed for coverage to become effective.
Applicant: Other: Co-Applicant Spouse Guarantor
E-Mail Address : E-mail Address :
Name:* Name:
Mother's Maiden Name: Mother's Maiden Name:
Account Number:* Account Number:
Social Security Number:* Social Security Number:
Driver's License Number/State:* Driver's License Number/State:
Cell Phone:* Cell Phone:
Birth Date:* Birth Date:
Home Phone:* Home Phone:
Business Phone/Ext.:* Business Phone/Ext.:
Present Address (street, city, state, zip):*

Years at this address:
Own Rent 		Present Address (street, city, state, zip):

Years at this address:
Own Rent
Previous Address (street, city, state, zip):

Years at this address:
Own Rent 		Previous Address (street, city, state, zip):

Years at this address:
Own Rent
Complete for joint credit, secured credit or if you live in a community property state:
Married Separated
Unmarried (single, divorced, widowed)		 Complete for joint credit, secured credit or if you live in a community property state:
Married Separated
Unmarried (single, divorced, widowed)
Employment/Income Employment/Income
Employment Income:*
$ per 		Employment Income:
$ per
Name of Employer:* Name of Employer:
Address of Employer:* Address of Employer:
Title/Grade: Title/Grade:
Start Date:* Hours at Work: Start Date: Hours at Work:
Supervisor's Name: Supervisor's Name:
If self-employed, type of business: If self-employed, type of business:
Notice: Alimony, child support, or separate maintenance income need not be
revealed if you do not choose to have it considered.
Other Income:
$ per
Source:
Other Income:
$ per
Source:
Other Income:
$ per
Source: 		Other Income:
$ per
Source:
Other Income:
$ per
Source: 		Other Income:
$ per
Source:
Other Income:
$ per
Source: 		Other Income:
$ per
Source:
Military: Is duty station transfer expected during next year? Yes No
If yes, where?
Ending/Separation date: 		Military: Is duty station transfer expected during next year? Yes No
If yes, where?
Ending/Separation date:

If employed less than five years:
Name of Previous Employer:
Address of Previous Employer:

Start Date:* End Date:

If employed less than five years:
Name of Previous Employer:
Address of Previous Employer:

Start Date: End Date:
Applicant Reference - Please provide the following information on the nearest relative not living with you: Other Reference - Please provide the following information on the nearest relative not living with you:
Name:* Name:
Address:* Address:
Relationship:* Relationship:
Home Phone:* Home Phone:
What You Owe
Rent*
Home Mortgage*		 Creditor Name:*
Present Balance:*
Monthly Payment:* Owed By:* Applicant Other
Other Creditor Name:*
Present Balance:*
Monthly Payment:* Owed By:* Applicant Other
Other Creditor Name:
Present Balance:
Monthly Payment: Owed By: Applicant Other
Other Creditor Name:
Present Balance:
Monthly Payment: Owed By: Applicant Other
Other Creditor Name:
Present Balance:
Monthly Payment: Owed By: Applicant Other
Other Creditor Name:
Present Balance:
Monthly Payment: Owed By: Applicant Other
Other Creditor Name:
Present Balance:
Monthly Payment: Owed By: Applicant Other
Other Creditor Name:
Present Balance:
Monthly Payment: Owed By: Applicant Other
Other Creditor Name:
Present Balance:
Monthly Payment: Owed By: Applicant Other
Total Owed Present Balance:
Monthly Payment:
List any names under which your credit references and credit history can be checked:
Co-Signer Debts
Rent
Home Mortgage		 Creditor Name:
Present Balance:
Monthly Payment: Owed By: Applicant Other
Other Creditor Name:
Present Balance:
Monthly Payment: Owed By: Applicant Other
Other Creditor Name:
Present Balance:
Monthly Payment: Owed By: Applicant Other
Other Creditor Name:
Present Balance:
Monthly Payment: Owed By: Applicant Other
Other Creditor Name:
Present Balance:
Monthly Payment: Owed By: Applicant Other
Other Creditor Name:
Present Balance:
Monthly Payment: Owed By: Applicant Other
Other Information About You
If you answer "yes" to any question other than #1, explain in the box below.
Applicant
Other
1. Are you a U.S. Citizen or Permanent Resident Alien?*
Yes No
Yes No

2. Do you currently have any outstanding judgments or have you ever filed for bankruptcy, had a debt adjustment plan confirmed under Chapter 13, had property foreclosed upon or repossessed in the last 7 years, or been a party in a lawsuit?*
Yes No
Yes No
3. Is your income likely to decline in the next two years?*
Yes No
Yes No
4. Are you a co-maker, co-signer, or guarantor on any loan not listed above?*
For Whom (name of others obligated on loan):

To Whom (name of creditor):
Yes No
Yes No
Comments:
State Law Notices

Ohio Residents Only: The Ohio laws against discrimination require that 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.
Wisconsin Residents Only: (1) No provision of any marital property agreement, unilateral statement under Section 766.59, or court decree under Section 766.70 will adversely affect the rights of the Credit Union unless the Credit Union is furnished a copy of the agreement, statement or decree, or has actual knowledge of its terms, before the credit is granted or the account is opened. (2) Please sign if you are not applying for this account or loan with your spouse. The credit being applied for, if granted, will be incurred in the interest of the marriage or family of the undersigned.
____________________________________________________________________
Signature for Wisconsin Residents Only

________________________________
Date

Signatures

1. You promise that everything you have stated in this application is correct to the best of your knowledge and that the above information is a complete listing of what you owe. If there are any important changes you will notify us in writing immediately. You authorize the Credit Union to obtain credit reports in connection with this application for credit and for any update, increase, renewal, extension, or collection of the credit received. You understand that the Credit Union will rely on the information in this application and your credit report to make its decision. If you request, the Credit Union will tell you the name and address of any credit bureau from which it received a credit report on you. It is a federal crime to willfully and deliberately provide incomplete or incorrect information on loan applications made to federal credit unions or state chartered credit union insured by NCUA.

By clicking the button, you are agreeing to the above statement.

Upon submission of your application, please fax a copy of your current pay stub to the credit union at (309) 693-2274. If you are self-employed, please also fax a copy of your 1040 form.
________________________________
Applicant's Signature and Date		 _________________________________
Other Signature and Date