APPLICATION MUST BE FILLED OUT IN FULL
CREDIT APPLICATION
NO ONE WILL RECEIVE FUNDS
Bank of Perry County
Bank of Lewis County
ON AUTO LOAN WITHOUT
of Bank of Perry
Lobelville and Linden, TN.
Branch
Hohenwald, TN
County
PROOF OF INSURANCE & TITLE
Amount Requested
No. Months
Proceeds To Be Used For -- If Home Loan, Furnish Address
Full Name
Age
Phone
Social Security Number
Mailing Address
Cell Phone
Residence Address if different from above
How Long
Date of Birth
Driver's License #
Exp. Date
Issue Date
Present Employer
How Long
Business Phone
(Do not complete if this is an application for individual unsecured credit.)
Married
■
Separated
■
Unmarried
■
Net Salary or Comm.
No. Dependents
Age of Dependents
Name and Address of nearest relative
GENERAL INFORMATION
Are
a defendant in any suits of legal action?
■
No
you
■
Yes
(Explain):
Have
been declared Bankrupt in the last 14
■
No
■
Yes (Explain):
you
years?
OUTSTANDING DEBTS
Creditor
Type Debt
Name Acct. Carried
Pres. Bal.
Monthly Pmts.
List Collateral Offered
Market Value
If Auto, Mileage
Credit References (name two)
Name of Insurance Agent:
DO NOT COMPLETE THIS SECTION UNLESS YOU ARE APPLYING FOR JOING CREDIT WITH A SPOUSE OR ANOTHER PERSON
Name of spouse or comaker (if any)
Age
Phone
Social Security Number
Relationship
Address
How Long
Date of Birth
Driver's License #
Exp. Date
Issue Date
Present Employer
Phone
Position
Net Salary or
Comm.
Everything that I have stated in this application is correct to the best of my knowledge. I understand that you will retain this appllication
whether or not it is approved. You are authorized to check my credit and employment history and to answer questions about your credit experience
with me.
Applicant's Signature
Date
Other Signature
Date
(Where Applicable)
BANK OF PERRY COUNTY,
TO
Lobelville-Linden, Tennessee
BANK OF LEWIS COUNTY, Hohenwald, TN
Branch of Bank of Perry County
TYPE OF CREDIT - CHECK THE APPROPRIATE
(Name of Lender)
❑
Individual - If you check this box, provide Financial Information only about yourself.
❑
Joint, with
Relationship
Financial Information about yourself and the other person.
PERSONAL FINANCIAL STATEMENT OF
NOTE: Any willful misrepresentation could result in a violation of Federal Law (Sec. 18 U.S.C. 1014)
Birth
Name
Date
Address
City
State/Zip
Social Sec. No
Home
Phone
No. of Dependents
Bus. or Occupation
Bus. Phone
ASSETS
LIABILITIES
Cash in hand and in bank
I owe notes to the following banks:
Loans due me, secured
Bank
Loans due
Bank
me, unsecured
Accounts due me
Cash values of insurance policies
Bank
Notes payable to relatives and friends
Notes payable to others
Stocks and bonds
Accounts and bills due others
United States securities
Premiums on life insurance
Live stock (see schedule)
Interest and taxes due
Grain and farm products (see schedule)
Cash rent
Other quick assets
TOTAL QUICK ASSETS
TOTAL CURRENT LIABILITIES
Farm land (see schedule)
Real estate mortgages
City and town property (see schedule)
Chattel mortgages
Farm implements and tools
Judgement and other liens
Grain products reserved for feeding stock
Machinery, viz., threshers, balers, tractors
Automobiles and trucks
Total Current and Defferred Liabilities
NET WORTH
TOTALS
TOTALS
SCHEDULE OF REAL ESTATE
TITLE IN THE NAME OF DESCRIPTION OF PROPERTY
ACRES
SEC.
LOT
TWP.
BLOCK
RANGE
DIV.
PRESENT VALUE
AMOUNT OF
INCUMBRANCE
MORTGAGE DUE
TOTAL
ANNUAL INCOME
ESTIMATE OF ANNUAL EXPENSES
Salary, Bonuses & Commissions
$
Income Taxes
$
Dividends & Interest
$
Other Taxes
$
Rental & Lease Income (Net)
$
Insurance Premiums
$
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.
Other Income - Itemize
$
Mortgage Payments
$
Rent Payable
$
Provide the following information only if Joint Credit is checked above.
Other Persons Salary, Bonuses & Commissions
$
Other Expenses
$
$
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.
Other Income of Other Person - Itemize
$
$
$
TOTAL
$
TOTAL
$
For the purpose of procuring credit from time to time, I/We furnish the foregoing as a true and accurate statement of my/our financial condition. Authorization is
hereby given to the Lender to verify in any manner it deems appropriate any and all items indicated on this statement. The undersigned also agrees to notify the
Lender immediately in writing of any significant adverse change in such financial condition.
If you check this box, provide
Statement Date
20
Date Signed
20
Signature
Signature
(Other Person if Applicable)
IMPORTANT APPLICATION INSURANCE DISCLOSURE
Borrower(s) Name/Address ("I", "Me", "My")
Lender(s) Name/Address
Bank of Perry County
P. 0. Box 341
Linden, TN 37096
The Lender may not condition an extension of credit on either.
(1)
My purchase of an insurance product from the lender or affiliates:
(2)
My agreement not to obtain, or a prohibition on me from obtaining, an insurance
product from an unaffiliated entity.
BY SIGNING BELOW, THE UNDERSIGNED ACKNOWLEDGES A VERBAL AND WRITTEN OF A COPY
OF THIS APPLICATION INSURANCE DISCLOSURE.
Signature
Date Signature
Date
