First State Bank » Serving Shannon & Polo, IL

Loan Application

* Required Fields

CREDIT APPLICATION - Consumer(non-Real Estate) Loans Only

IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT 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 opens an Account. Identity verification also helps to protect you and us from identity fraud.

What this means for you:
When you 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.

TYPE OF CREDIT REQUESTED

IMPORTANT: Check the appropriate boxes below and complete the applicable sections.

*Select One	*Select One
SECURED	INDIVIDUAL CREDIT - relying solely on my income or assets.
UNSECURED	INDIVIDUAL CREDIT - relying on my income or assets as well as income or assets from other sources
	JOINT CREDIT

AMOUNT REQUESTED* $	TERM IN YEARS*	PAYMENT DATE DESIRED	WANT TO REPAY Monthly Other
PROCEEDS OF LOAN TO BE USED FOR*

SECTION A - INDIVIDUAL APPLICANT INFORMATION

NAME* (Last, First Middle)

PHONE*

S.S. NUMBER*

DATE OF BIRTH*

ADDRESS*(Street, City, State, ZIP)

COUNTY

DO YOU
Own Rent

HOW LONG

NEXT OF KIN (Format: Name - Relationship)*

EMPLOYER* (Company Name & Address)

HOW LONG

BUSINESS PHONE

EXT.

POSITION/TITLE *

SALARY PER MONTH*
Gross: $

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:

Court Order
Written Agreement
Oral Understanding

SOURCES OF OTHER INCOME

AMOUNT PER MONTH
$

HAVE YOU PREVIOUSLY RECEIVED CREDIT FROM US?
Yes No
WHEN:

SECTION B - JOINT APPLICANT OR OTHER PARTY INFORMATION
"Complete Only if: for joint credit, for individual credit relying on income or assets from other sources or if applicant is married and resides in a community property state."

RELATIONSHIP TO APPLICANT (if any)

NAME (Last, First Middle)

PHONE

S.S. NUMBER

DATE OF BIRTH

ADDRESS(Street, City, State, ZIP)

COUNTY

DO YOU
Own Rent

HOW LONG

EMPLOYER (Company Name & Address)

HOW LONG

BUSINESS PHONE

EXT.

POSITION/TITLE

SALARY PER MONTH
Gross: $

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:

Alimony, child support, separate maintenance received under:

Court Order
Written Agreement
Oral Understanding

SOURCES OF OTHER INCOME

AMOUNT PER MONTH
$

HAVE YOU PREVIOUSLY RECEIVED CREDIT FROM US?
Yes No WHEN:

SECTION C - MARITAL STATUS
“Complete only if: for joint or secured credit or if applicant resides in a community property state or is relying on property located in such a state as a basis for repayment of the credit requested.”

APPLICANT*	Married	Separated	Unmarried (including single, divorced, and widowed)
OTHER PARTY	Married	Separated	Unmarried (including single, divorced, and widowed)

SECTION D
Complete the following information about both the Applicant and Joint Applicant or Other Person (if applicable)

Are you obligated to make Alimony, Support or Maintenance Payments?* No Yes

If yes, to (Name & Address):
Amt. Per Month: $

Are you a co-maker, endorser, or guarantor on any loan or contract?* No Yes

If yes: For whom? To whom?

Are there any unsatisfied judgments against you?* No Yes
If yes, to whom?
Amount: $

Have you been declared bankrupt in the last 10 years?* No Yes
If yes, where?
Year

SECTION E - SECURED CREDIT

Complete only if credit is to be secured. Briefly describe the property to be given as security:

PROPERTY DESCRIPTION

NAME & ADDRESS OF ALL CO-OWNERS OF THE PROPERTY

SECTION F - Other Information

0 remaining

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: 1) My purchase of an insurance product or annuity from your or from any of your affiliates; 2) 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.

*– I CERTIFY that everything I have stated in this application and on any attachments is correct. You may keep this application whether or not it is approved. By clicking the "Submit" button below, I authorize you to check my credit and employment history and to answer questions others may ask you about my credit record with you. I understand that I must update credit information at your request if my financial condition changes.

FDIC

Equal Housing Lender

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