Credit Application Form

* - Indicates required fields

Are you applying as a single applicant or as joint applicants? *

Single Applicant Joint Applicants

General Application Details

Amount of Loan Requested

Payment Date Desired (e.g. 1st, 20th, etc.)

Purpose/Use of Credit Proceeds

Secured or Unsecured Credit *

Secured Credit Unsecured Credit

Applicant Information

Full Name (First, Middle, Last) *

Home/Cell Phone *

Date of Birth *

Social Security Number *

Present Address

Street Address *

City/State *

Zip *

How long at this address? *

Employment Information

Present Employer Name & Address *

Position/Title *

How long at this employer? *

Business Phone *

Applicant Asset & Debt Information

Assets and Liabilities

Cash & Deposits in Financial Institutions

Securities (Stocks, Bonds)

Securities Brokerage Firm

Retirement Accounts

Brokerage Company

Retirement Account Type (e.g. 401k, Roth IRA, etc.)

Brokerage Company

Retirement Account Type (e.g. 401k, Roth IRA, etc.)

Brokerage Company

Retirement Account Type (e.g. 401k, Roth IRA, etc.)

Brokerage Company

Retirement Account Type (e.g. 401k, Roth IRA, etc.)

Brokerage Company

Retirement Account Type (e.g. 401k, Roth IRA, etc.)

Real Estate

Type & Address (e.g. Primary Residence, Vacation Home, Rental, etc.)

Amount Owed

Monthly Payment

Type & Address (e.g. Primary Residence, Vacation Home, Rental, etc.)

Amount Owed

Monthly Payment

Type & Address (e.g. Primary Residence, Vacation Home, Rental, etc.)

Amount Owed

Monthly Payment

Type & Address (e.g. Primary Residence, Vacation Home, Rental, etc.)

Amount Owed

Monthly Payment

Type & Address (e.g. Primary Residence, Vacation Home, Rental, etc.)

Amount Owed

Monthly Payment

Vehicles

Make & Model

Amount Owed

Monthly Payment

Make & Model

Amount Owed

Monthly Payment

Make & Model

Amount Owed

Monthly Payment

Make & Model

Amount Owed

Monthly Payment

Make & Model

Amount Owed

Monthly Payment

Other Assets

Description

Credit Card Balance

Monthly Payment

Personal Loan Balance

Monthly Payment

Other Loan Balance

Monthly Payment

Income and Expense

Monthly Earnings

(combined: salary, wages, commissions, bonus)

Other Monthly Income

Type (Dividends, Retirement, Social Security, Unemployment, Disability, Alimony, Child Support, etc.)

Rent Monthly Expense - If Applicable

Other Monthly Expense

Type (Judgement, Alimony, Child Support, etc.)

If any income is likely to be reduced before credit is paid off, please explain:

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.

Are you a co-maker, endorser, or guarantor on any loans/contracts that are not listed above?

Yes No

Any unsatisfied judgments against you?

Yes No

Have you been declared bankrupt in the last 10 years?

Yes No

Joint Applicant Asset & Debt Information

Same As Applicant

Assets and Liabilities

Cash & Deposits in Financial Institutions

Securities (Stocks, Bonds)

Securities Brokerage Firm

Retirement Accounts

Brokerage Company

Retirement Account Type (e.g. 401k, Roth IRA, etc.)

Brokerage Company

Retirement Account Type (e.g. 401k, Roth IRA, etc.)

Brokerage Company

Retirement Account Type (e.g. 401k, Roth IRA, etc.)

Brokerage Company

Retirement Account Type (e.g. 401k, Roth IRA, etc.)

Brokerage Company

Retirement Account Type (e.g. 401k, Roth IRA, etc.)

Real Estate

Type & Address (e.g. Primary Residence, Vacation Home, Rental, etc.)

Amount Owed

Monthly Payment

Type & Address (e.g. Primary Residence, Vacation Home, Rental, etc.)

Amount Owed

Monthly Payment

Type & Address (e.g. Primary Residence, Vacation Home, Rental, etc.)

Amount Owed

Monthly Payment

Type & Address (e.g. Primary Residence, Vacation Home, Rental, etc.)

Amount Owed

Monthly Payment

Type & Address (e.g. Primary Residence, Vacation Home, Rental, etc.)

Amount Owed

Monthly Payment

Vehicles

Make & Model

Amount Owed

Monthly Payment

Make & Model

Amount Owed

Monthly Payment

Make & Model

Amount Owed

Monthly Payment

Make & Model

Amount Owed

Monthly Payment

Make & Model

Amount Owed

Monthly Payment

Other Assets

Description

Credit Card Balance

Monthly Payment

Personal Loan Balance

Monthly Payment

Other Loan Balance

Monthly Payment

Income and Expense

Monthly Earnings

(combined: salary, wages, commissions, bonus)

Other Monthly Income

Type (Dividends, Retirement, Social Security, Unemployment, Disability, Alimony, Child Support, etc.)

Rent Monthly Expense - If Applicable

Other Monthly Expense

Type (Judgement, Alimony, Child Support, etc.)

If any income is likely to be reduced before credit is paid off, please explain:

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.

Are you a co-maker, endorser, or guarantor on any loans/contracts that are not listed above?

Yes No

Any unsatisfied judgments against you?

Yes No

Have you been declared bankrupt in the last 10 years?

Yes No

Federal Credit Application Insurance Disclosure

Please acknowledge: I have applied for an extension of credit with Liberty National Bank. Federal law prohibits Liberty National Bank for conditioning the extension of credit on either:

My purchase of an insurance product or annuity from you or from any of your affiliates; or
My agreement not to obtain or a prohibition on me from obtaining an insurance product or annuity from an unaffiliated entity.

Insurance Products and annuities are not deposits, not insurance by FDIC, not guaranteed by Liberty National Bank, and may involve investment risk, including possible loss of value.

Electronic Disclosure Consent

By submitting this application, I (we) certify that the information provided is true and complete, and that I (we) am/are the person(s) submitting this application. I (we) authorize the bank to obtain a consumer report in connection with this application for credit and understand that the bank may verify this information for identity fraud purposes.

Signature(s)

Applicant Signature *

Date *

Credit Application Form