Credit Application

Assets & Liabilities

Disclosure

Important Information:

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. What this means for you: When you open an account, or apply for a loan, we will ask 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.

Please indicate whether you intend to apply for individual or joint credit. Applicants for joint credit should complete the applicable co-borrower sections of the application. Co-borrower information must be provided when the income or assets of a person other than the "Borrower" (including the Borrower's spouse) will be used as a basis for loan qualification, or the income or assets of the Borrower's spouse will not be used as a basis for loan qualification, but his or her liabilities must be considered because the Borrower resides in a community property state, the secured property is located in a community property state, or the Borrower is relying on other property located in a community property state as a basis for repayment of the loan.

You must be a U. S. Citizen with a U.S. address and Social Security number to apply online. All other applicants should contact us at 701-782-6295 .

APPLICATION INFORMATION
Application for:	Amount Requested:
Application Type: Individual Joint
Purpose of Loan:

BORROWER
Name		D.O.B. (MM/DD/YY)	School Yrs Attended:
Present Street Address Notice: Do not enter a P. O. Box unless you are currently serving in the military.	City: State: ZIP Code:
	Number of Years at this address: Own Rent
Former Street Address	City: State: ZIP Code: (if less than 2 years at present address)
Former Street Address	Number of Years at this address: Own Rent
Driver's License Number		Phone # (000-000-0000)
DL State Issued		Business Phone (000-000-0000)
Social Security Number		Email
Marital Status Married Unmarried (including single, divorced, widowed) Separated		Notice: Marital status should only be completed if applicant is applying for joint or secured credit, or if applicant resides in a community property state, or is relying on property located in such a state.
Dependents other than listed by Co-Borrower: No. Ages
Name of Employer		Years employed in this line of work or profession? yrs.
Street Address		Years on this job
City State Zip		Self-employed
Position/Title		Type of Business

CO-BORROWER
Name		D.O.B. (MM/DD/YY)	School Yrs Attended:
Present Street Address Notice: Do not enter a P. O. Box unless you are currently serving in the military.	City: State: ZIP Code:
	Number of Years at this address: Own Rent
Former Street Address	City: State: ZIP Code: (if less than 2 years at present address)
Former Street Address	Number of Years at this address: Own Rent
Driver's License Number		Phone # (000-000-0000)
DL State Issued		Business Phone (000-000-0000)
Social Security Number		Email Address
Marital Status Married Unmarried (including single, divorced, widowed) Separated		Notice: Marital status should only be completed if applicant is applying for joint or secured credit, or if applicant resides in a community property state, or is relying on property located in such a state.
Dependents other than listed by Co-Borrower: No. Ages
Name of Employer		Years employed in this line of work or profession? yrs.
Street Address		Years on this job
City State Zip		Self-employed
Position/Title		Type of Business

GROSS MONTHLY INCOME				MONTHLY HOUSING EXPENSE
Item	Borrower	Co-Borrower	Total	Item	Total
Base Empl. Income	$	$	$	Rent	$
Overtime				First Mortgage (P&L)
Bonuses				Other Financing
Commissions				Hazard Insurance
Dividends/Interest				Real Estate Taxes
Net Rental Income				Mortgage Insur.
Other+ (Before completing, see notice under Describe Other Income below)				Homeowner Assn. Dues
Total	$	$	$		$

DESCRIBE OTHER INCOME
NOTICE: Alimony, child support, or separate maintenance income need not be revealed if the Borrower or Co-Borrower does not choose to have it considered as a basis for repaying this loan.
Item	Monthly Amount
	$

THESE QUESTIONS APPLY TO BOTH BORROWERS
	B Y/N	C Y/N		B Y/N	C Y/N
If a yes answer is given to a question in this section, explain on an attached sheet.			Are you a co-maker or endorser on a note?
			Are you obligated to pay alimony, child support, or separate maintenance?
Have you any outstanding judgments?			Do you have health and accidental insurance?
In the last 14 years, have you been bankrupt?			Do you have major medical coverage?
Have you had property foreclosed upon or given title or deed in lieu of?			Are you a U. S. Citizen?
Are you a party in a law suit?			Are you a permanent resident alien?

This statement and any applicable supporting schedules may be completed jointly by both married and unmarried co-borrowers if assets and liabilities are sufficiently joined so that the Statement can be meaningfully and fairly presented on a combined basis; otherwise separate statements and schedules are required. If the co-borrower section was completed about a spouse, this statement and supporting schedules must also be completed about that spouse.

Completed: Individual Jointly

Assets (Description)	Cash or Market Value
Name and address of Bank, S&L, or Credit Union (List checking and savings accounts)
Acct. No.	$
Name and address of Bank, S&L, or Credit Union (List checking and savings accounts)
Acct. No.	$
Name and address of Bank, S&L, or Credit Union (List checking and savings accounts)
Acct. No.	$
Name and address of Bank, S&L, or Credit Union (List checking and savings accounts)
Acct. No.	$
Stocks & Bonds (Company name/number & description)	$
Life Insurance net cash value: Face amount: $	$
Subtotal Liquid Assets	$
Real Estate owned (enter market value from schedule of real estate owned)	$
Vested interest in retirement fund	$
Net worth of business(es) owned (attach financial statement)	$
Automobiles owned (make and year)	$
	$
	$
Other Assets (itemize)	$
Total Assets a.	$

Liabilities and Pledged Assets. List the creditor's name, address and account number for all outstanding debts, including automobile loans, revolving charge accounts, real estate loans, alimony, child support, stock pledges, etc. Use continuation sheet, if necessary.

Liabilities	Monthly Payment	Unpaid Balance
Name and address of Company Acct. No.	$	$
Name and address of Company Acct. No.	$	$
Name and address of Company Acct. No.	$	$
Name and address of Company Acct. No.	$	$
Name and address of Company Acct. No.	$	$
Name and address of Company Acct. No.	$	$
Alimony/Child Support/Separate Maintenance Payments Owed to:	$
Job Related Expense (child care, union dates, etc.)	$
Total Monthly Payments	$
Total Liabilities b.		$

SCHEDULE OF REAL ESTATE OWNED (If Additional Properties Owned Attach Separate Schedule)
Address of Property	Type of Property*	Present Market Value	Amt. of Mortgages & Liens	Gross Rental Income	Mortgage Paymts.	Taxes, Ins., Maint. and Misc.	Net Rental Income
		$	$	$	$	$	$


TOTALS		$	$	$	$	$	$
* Indicate S if Sold, PS if Pending Sale or R if Rental being held for income

LIST PREVIOUS CREDIT REFERENCES
Borrower or CoBorrower	Creditor's Name and Address	Account Number	Purpose	Highest Balance	Date Paid




List any additional names under which credit has previously been received.

IF EMPLOYED IN CURRENT POSITION LESS THAN 2 YEARS COMPLETE THE FOLLOWING

Previous Emplr./School

City/State

Type of Bus.

Position/Title

Monthly Income

I/We certify that the information on this application is true and complete to the best of my/our knowledge. The Bank of Hazelton is authorized to verify, exchange and retain credit and employment information contained herein and relative to this application.