United Credit Union

Applicant Account Number Amount Requested $ Loan Type Borrower First Name Mi Last Name Social Security Number - - Phone - - Current Street Address City/Town State Zip Rent Own Live with Parents/Relatives Driver's License No. - - State Borrower's Employment and Income Current Employer Date Hired - - Position Source(s) of other income Total Monthly Gross Income $ Co-Borrower First Name Mi Last Name Social Security Number - - Phone - - Current Street Address City/Town State Rent Own Live with Parents/Relatives Driver's License No. - - State Co-Borrower's Employment and Income Current Employer Date Hired - - Position Source(s) of other income Total Monthly Gross Income $ Assets Including: Checking & Savings accounts, Real Estate, Automobiles, Stocks, Bonds Description Value Balance $ Description Value Balance $ Description Value Balance $ Description Value Balance $ Description Value Balance $ Description Value Balance $ Obligations Rental / Mortgage Payment $ How would you like us to respond? Phone number – - - Email Address When is the best time to contact you? I hereby certify that all statements made are true and complete and submitted for the purpose of obtaining credit. In considering this application the loan officer may request and use a report from outside credit reporting agencies. We may also ask a reporting agency or agencies for other such reports in connection with renewal or continuation of the credit for which you are applying. If you request it, we will tell you whether or not we asked for such a report, and if we have the name and address of the agency or agencies as well as how to request a copy for your records will be released to you. "SOURCE OF OTHER INCOME: You are not required to disclose income from alimony, child support or separate maintenance payments. However, if you are relying on income from alimony, child support or separate maintenance as a basis for repayment of this obligation please complete this information. CREDIT INSURANCE DISCLOSURE: I understand that Single Life Credit Insurance is a condition of obtaining credit at United Credit Union. United does not require that I obtain life coverage through United (although it is available) but does require that life coverage be provided through a carrier of my choice and assigned to United. The amount of coverage must equal the total indebtedness up to a maximum of $75,000.00 through age 75 at all times. Joint Credit Life Insurance and Single Credit Insurance are available through United, but will not be provided unless I agree (please check one- yes no) and agree to pay the additional premium cost Yes, I want mandatory Single Credit Life Insurance through the United Credit Union. (type in initial) Yes, I want voluntary Joint Credit Life Insurance through the United Credit Union. (type in initial) Yes, I want voluntary Single Credit Disability Insurance through the United Credit Union. (type in initial) Yes, I will provide Single Life Insurance through a carrier of my choice. (type in initial) If you checked yes, the credit union will disclose the actual cost/estimate of this insurance to you. They will ask you to sign and date an enrollment form which will disclose the terms and conditions of the credit insurance. AGREEMENT: This statement is submitted to obtain credit and I certify that all information herein is true and complete. I also authorize United Credit Union to conduct further investigation and obtain additional information concerning my credit reputation from all available sources from time to time. NOTE: 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. Applicants Name: Date: