,
VMPC148 (1408).00
UCA 8/1/2014
Page 1 of 4
*
VMP
-
Universal Credit Application
2012Wolters Kluwer Financial Services
Bankers Systems
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.
Account No.
3. Applicant Information
Security for CreditLoan Purpose
Applicant
2. Type of Requested Credit
1. Type of Application
Class No. Date Received
First Payment Date
Proceeds of Credit to Be Used for
Repayment Interval
$
Previous Address
Primary Phone
Have you ever received credit from us?
No. of Months
Individual Credit - You are relying on your income or assets as well
as income or assets from other sources.
Credit Type
Amount Financing Type
Gov't ID Type Gov't ID No. Gov't ID Issued By
Gov't ID Issue Date Gov't ID Exp. Date Date of Birth
Soc. Sec. No.
Email Address:
Present Address
Second Phone
Name:
Address:
Telephone:
l
Creditor
("You" means Applicant, et al; and "We" means Creditor)
Monthly
Application Date
Check only one of the three types:
Joint Applicant
l
l
l
Applicant
Joint Credit - By initialing below, you intend to apply for "joint credit".Individual Credit - You are relying solely on your income or assets.
l
l
l
l
To purchase property that will secure your credit
To purchase property that is a residential dwelling and is not real estate
To finance home improvements to a residential dwelling
Other (describe):
l
l
l
New
Refinance
Modification
l
l
l
l
Line of Credit
Loan
Sale
Lease
l
l
l
Agricultural
Business
Consumer
Unsecured
Secured
l
l
Insider (Shareholder, Director, Officer)
office/branch:
No. of Yrs.:
Nearest Relative (not living with you)
Your Relationship to us (or our affiliate)
l
If yes, when:
l
Employee
l
l
l
l
None
l
l
Own
Yes
Ages:
l
Rent
ll
Own Rent
l
No
No. of Yrs.:
No.:Dependents
l
CellCell
Full Name (First, Middle, Last)
For Creditor Use
Joint Applicant or Other Party
Previous Address
Primary Phone
Have you ever received credit from us?
Gov't ID Type Gov't ID No. Gov't ID Issued By
Gov't ID Issue Date Gov't ID Exp. Date Date of Birth
Soc. Sec. No.
Email Address:
Present Address
Second Phone
Name:
Address:
Telephone:
Insider (Shareholder, Director, Officer)
office/branch:
No. of Yrs.:
Nearest Relative (not living with you)
Your Relationship to us (or our affiliate)
l
l
If yes, when:
l
Employee
l
l
l
l
None
l
l
Own
Yes
Cell
Ages:
l
Rent
ll
Own Rent
l
No
No. of Yrs.:
No.:Dependents
l
Cell
l
Cell
l
Cell
l
l
Full Name (First, Middle, Last)
l
l
l
l
About
Printing Requirements
Reset
Show Field Borders
CornerStone State Bank
406 E. Commerce Drive
Belle Plaine, MN 56011
Ph: 952-873-2500
Fax: 952-873-2500
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.
Outstanding Debts (This section should be charge accounts, installment contracts, credit cards, rent, mortgages and other obligations.)
$
$
$
$
$
$
$
$
$
$
$
$
Continuation Form
l
Continuation Form
Assets Owned
$
$
$
$
$
$
$
$
$
$
$
$
$
Mortgage
Amounts from
Total Assets
Date Paid in Full
l
Total Debts
$
Amounts from
Credit References - Name
$
$
$
$
$
$
$
$
$
$
$
$
l
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
l
Rent Payment
Original Amount Borrowed
$
$
$
Type of Asset or
Description
Account Number
Asset Owner's NameCurrent Market Value Remaining Balance of Lien
(Enter "0" if none)
Landlord
Type of Debt, or
Account Number
Creditor Name
Original Amount
Present
Balance
Debtor's Name Past Due
(Yes/No)
Monthly
Payment
$$
,
VMPC148 (1408).00
UCA 8/1/2014
Page 2 of 4
*
VMP
-
Universal Credit Application
2012Wolters Kluwer Financial Services
Bankers Systems
,
VMPC148 (1408).00
UCA 8/1/2014
Page 3 of 4
*
VMP
-
Universal Credit Application
l
8. Property Information (if secured)
Applicant
Previous
Joint Applicant or Other Party
1st Employer:
Court order
ll
Current
Yes (Explain in section 10.)
Self
l
Phone:
$
Applicant Joint Applicant or Other Party
Agricultural
Business
Consumer
7. Other Obligations
l
l
l
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.
l
No. of Yrs.:
Oral understanding
l
Name:
Address:
Mgr.:
Gross Monthly Salary/Comm.:
Position/Title:
Previous
Phone:
$
l No
per Month$
Source:
l
Other Income:
l Written agreement
Alimony, child support, separate maintenance received under:
l
Applicant Joint Applicant or Other Party
Primary Use of Property
5. Employment Information
ll l
Where:
Year:
Yes
l
No If yes,
l l
Amount: $
For whom:
To whom:
Yes No If yes,
l
ll l
Amount per month: $
To whom:
Yes No If yes,
l l
Amount per month: $
To whom:
Yes No If yes,
Name:
Address:
Mgr.:
Gross Monthly Salary/Comm.:
Position/Title:
Phone:
$
Is any income listed in Sections 4, 5 or 6 likely to be reduced before the
credit is paid off:
Property Owner(s) Names & Addresses
Boat or Vessel
Certificate of Deposit
Deposit Account
Manufactured Home
Motor Vehicle
l
l
l
l
l
l
Name:
Address:
Mgr.:
Gross Monthly Salary/Comm.:
Position/Title:
Yes (Explain in section 10.)l
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.
Alimony, child support, separate maintenance received under:
Homestead Property
l No
per Month$
Source:
Other Income:
Court orderl
l Residential Dwelling
Are you obligated to make Alimony, Support or
Maintenance Payments?
Previous
l
Current Self No. of Yrs.:
l
Previous1st Employer:
ll
Current Self No. of Yrs.:
Phone:
$
l
l
Previous
3rd Employer:
ll
Current Self No. of Yrs.:
Name:
Address:
Mgr.:
Gross Monthly Salary/Comm.:
Position/Title:
l
Phone:
$
2nd Employer:
Name:
Address:
Mgr.:
Gross Monthly Salary/Comm.:
Position/Title:
Phone:
$
Name:
Address:
Mgr.:
Gross Monthly Salary/Comm.:
Position/Title:
6. Other Income
Property DescriptionProperty Type Property Location and Address
ll Written agreement Oral understanding
ll l
Where:
Year:
Yes
l
No If yes,
l l
Amount: $
For whom:
To whom:
Yes No If yes,
l
ll l
Amount per month: $
To whom:
Yes No If yes,
l l
Amount per month: $
To whom:
Yes No If yes,
Is any income listed in Sections 4, 5 or 6 likely to be reduced before the
credit is paid off:
Are you a co-maker, endorser, co-signer, surety, or
guarantor on any loan, contract or other obligation?
Are there any unsatisfied judgments against you?
Have you been declared bankrupt in the last 10 years?
l
Current Self No. of Yrs.:
l
2nd Employer:
lll
3rd Employer: Current Previous Self No. of Yrs.:
2012Wolters Kluwer Financial Services
Bankers Systems
10. Additional Information or Explanations
12. Certifications, Authorizations and Signatures
Married
Separated
Unmarried (including single, divorced, widowed)
l
l
l
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.
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.
Married
Separated
Unmarried (including single, divorced, widowed)
l
Applicant Joint Applicant or Other Party
9. Marital Status
Electronic Signature. If checked, You further agree that you have signed this Credit Application with one or more electronic signatures. You
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.
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.
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.
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.
California Residents. Each applicant, if married, may apply for a separate account.
11. Notices
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.
Notice: It is a federal crime punishable by fine, imprisonment, or both, to knowingly make any false statements concerning any of the above facts
as applicable under the provisions of Title 18, United States Code § 1001, et seq.
l
l
l
Mortgage Loan Originator Information
For Creditor Use
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.
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:
} Mortgage Loan Originator Name and Identifier:
} Mortgage Loan Origination Company Name and Identifier:
DateDate
(if applicable)
Applicant Signature Joint Applicant, or Other Party, Signature
Reason Code(s)Date Received Received By Date Action Taken Action Taken By Action Taken
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.
,
VMPC148 (1408).00
UCA 8/1/2014
Page 4 of 4
*
VMP
-
Universal Credit Application
2012Wolters Kluwer Financial Services
Bankers Systems
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome