Credit Application Iuka State Bank

Name(Required)

First Middle Last

Date of Birth(Required)

Driver's License #(Required)

Social Security #(Required)

Cell Phone(Required)

E-mail Address(Required)

Present Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Rent or Own?(Required)

Rent

Own

Monthly Housing Cost(Required)

How Long at Present Address?(Required)

Employment Information

Present Employer(Required)

Company Name

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Time with Current Employer(Required)

Position/Title

Name of Supervisor

Business Phone and Ext.

Present Gross Salary/Commission(Required)

Present Net Salary/Commission(Required)

No. Dependents

Age of Dependents

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

Other Income

Source(s) of Other Income

Other Applicant

Complete only if: for joint credit, for individual credit relying on income or assets from other sources, or applicant is married and resides in a community property state.

Name

First Middle Last

Date of Birth

Driver's License #

Social Security #

Cell Phone

E-mail Address

Present Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Rent or Own?

Rent

Own

Monthly Housing Cost

How Long at Present Address?

Employment Information

Present Employer

Company Name

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Time with Current Employer

Position/Title

Name of Supervisor

Business Phone and Ext.

Present Gross Salary/Commission

Present Net Salary/Commission

No. Dependents

Age of Dependents

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

Other Income

Source(s) of Other Income

Marital Status

Complete only if: for joint or secured credit, or 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

Other Party

Married

Separated

Unmarried (including, single, divorced, and widowed)

Applicant

Married

Separated

Unmarried (including, single, divorced, and widowed)

Are you a co-maker, endorser or guarantor on any loan or contract?

Yes

Are there any unsatisfied judgements against you?

Yes

Have you been declared bankrupt in the last 14 years?

Yes

Loan Details

Loan Purpose(Required)

Loan Amount Requested(Required)

Loan Term in Months(Required)

Everything that I have stated in this Application is correct to the best of my knowledge. I understand that you will retain this Application 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. It is illegal to reveive credit by wrongfully stating income, assets, or other information on this form. I understand that I must update credit information at your request if my financial condition changes.

Applicant Signature(Required)

First Last

Date(Required)

Other Signature (Where Applicable)

First Last

Date

Banking Sign In