Date Applicaon Received: ___________
Membership Emergency Loan Applicaon
MEMBERSHIP EMERGENCY LOAN APPLICATION | 2020.07
Name: _____________________________________________________________ T# ___________ DOB_____________
Address: ________________________________________ City: ______________________ State: _____Zip: __________
Phone #_______________________ Message #_______________________ E-Mail_______________________________
THIRD PARTY DOCUMENTATION REQUIRED FOR ALL EMERGENCY LOANS
□Natural Disaster _____________________________ Amount $ _______
1. Official third party documentation_________________________
□Loss of an Immediate Family Member (up to $1000.00)
(Parent, Sibling, Spouse, Child)
1. Official third party documentation_________________________
---------------------------------------
Once per 12-month period
□Essential utility shut off PAYABLE TO: ___________________________
1. Disconnection notice must reflect Applicant Name
2. Completed W-9 Form if not Snohomish PUD or City of Marysville
□Eviction Notice PAYABLE TO: _________________________________
1. Eviction notice
2. Copy of Lease Agreement
3. Completed W-9 Form
REPAYMENT opon
$___________Monthly Distribuon
$ __________ Monthly Senior Distribuon
$ __________ Bi-Monthly Elder Support
$ __________ Bi-Monthly Disability
$ __________ Bi-Weekly Payroll deducon Check: TTT TGO QCV
The Tulalip Membership Loan Policy includes a 9% interest per annum on all loans, the minimum required monthly payment per the
policy applies to Emergency Loans. By signing this applicaon I aest the informaon I have provided is true and agree to the terms
of the Membership Loan Policy. I acknowledge this loan will be combined with any current loan and the pre-determined payment
schedule for a single loan payment.
□ Color copy of Tribal ID attached
_______________________________________________________ ________________________
Signature Date
POWER OF ATTORNEY WILL NOT BE ACCEPTED
ELIGIBILITY REVIEW
Monthly Distribuon available amount
$________________
Loan Balance $________________________
Last Emergency Loan:
Ulity _____/_____/_______
Evicon _____/_____/_______
□ Approved □ Disapproved
□ Issued within two business days
Emergency Loan amount $______________
Notes:_______________________________
____________________________________
____________________________________
____________________________________
_________________
___________________
V
endor ID: ___________________
□ New
Reviewed by: _________________________
2
nd
Review by: ________________________
Entered by: __________________________
TDS-35555 (07/2020)
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