Important Applicant Information: Federal law requires financial institutions to obtain sufficient information to verify your identity. You could be asked multiple questions and to provide one or more forms of identification to fulfill this requirement. In some instances the Citizens Bank of Ashville may use outside sources to confirm the information. The information you provide is protected by our privacy policy and under federal law.
For Institution Use Only: Date: __________ Class No. __________ Account No. __________
Approved by __________ Declined by __________
Type of Credit Requested
IMPORTANT: Mark the Appropriate boxes below and complete the applicable sections.
Secured
Individual Credit - relying solely on my personal income or assets
Unsecured
Individual Credit - relying on my personal income or assets as well as income or assets from other sources
Joint Credit - we intend on applying for joint credit. (all parties initials) _______________
Amount Requested
Term of Loan
Payment Date Desired
Repayment Terms
Proceeds of Loan to be Used for
Monthly
Other - Specify
Part 1 - Individual Applicant Information
Last name
First Name
Middle Name
Birth Date
Home Phone No.
Cell Phone No.
Social Security No.
Driver's License No.
No. of Dependants
Ages of Dependents
Address (Street, City, State and Zip)
County
Do you currently
Own
How Long
Rent
Previous Address (Street, City, State and Zip) Complete if less than three years at current address
County
Did you previously
Own
How Long
Rent
Name and Address of Nearest Relative Not Living with You
Relationship
Contact's Phone No.
Applicant's Present Employer (Company Name and Address)
How Long
Business Phone
Ext.
Position or Title
Take Home Salary Per Month
Previous Employer (Company Name and Address) If less than two years.
How Long
Alimony, child support, or separate maintenance income need not be revealed if you do not wish it considered as a basis for repaying this obligation.
Alimony, child support, separate maintenance received under: Court Order
Written Agreement
Oral Understanding
Other Sources of Income
Amount Per Month
Is any income listed in this Part 1 likely to be reduced before the credit request is paid off?
No
Yes (Please Explain)
Have you previously received credit from the Citizens Bank of Ashville?
No
Yes (When ?)
Part 2 - Joint Applicant or Other Party Information
Last name
First Name
Middle Name
Birth Date
Home Phone No.
Cell Phone No.
Social Security No.
Driver's License No.
No. of Dependants
Ages of Dependents
Relationship to Applicant (If any)
Address (Street, City, State and Zip)
County
Do you currently
Own
How Long
Rent
Present Employer (Company Name and Address)
How Long
Business Phone
Ext.
Position or Title
Take Home Salary Per Month
Previous Employer (Company Name and Address) if less than two years.
How Long
Alimony, child support, or separate maintenance income need not be revealed if you do not wish it considered as a basis for repaying this obligation.
Alimony, child support, separate maintenance received under: Court Order
Written Agreement
Oral Understanding
Other Sources of Income
Amount Per Month
Is any income listed in this Part 2 likely to be reduced before the credit request is paid off?
No
Yes (Please Explain)
Has the Joint Applicant or Other Party ever received credit from the Citizens Bank of Ashville?
No
Yes (When ?)
Part 3 - 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.
Applicant
Married
Separated
Unmarried (including single, divorced, and widowed)
Other Party
Married
Separated
Unmarried (including single, divorced, and widowed)
Part 4 - Assets and Debts Information
If Part 2 has been completed, this section should be completed by both the Applicant and the Joint Applicant or Other Person describing all requested information.
Assets Owned (attach additional sheet if necessary)
Description of Assets
Primary Name on Account / Owner
Value "$"
Checking Accounts
(Account No., Institution)
1
2
3
4
5
Savings Accounts
(Account No., Institution)
1
2
3
4
5
Certificate of Deposits
(Account No., Institution)
1
2
3
4
5
Marketable Securities
(Issuer, Type, No. of Shares)
1
2
3
4
5
Real Estate
(Address / Location, Date Acquired)
1
2
3
4
5
Life Insurance
(Issuer, Face Value, Owner, Cash Value)
1
2
3
4
5
Automobiles / Vehicles
(Make, Model, Year)
1
2
3
4
5
Other
(Describe)
1
2
3
4
5
Total Assets
Outstanding Debts (attach addition sheet if necessary)
Description of Debt
Primary Name on Account / Owner
Original Amount
Present Amount
Monthly Payment
Rent
Landlord
Mortgage
Account No.
Mortgage Holder
1
2
3
4
5
Automobiles / Vehicles
(Make, Model, Year)
Account No.
Primary Name
Lien Holder
1
2
3
4
5
Charge Credit Accounts and No.
Primary Name / Cardholder
Credit Limit
Current Balance
Monthly Payment
1
2
3
4
5
Other Accounts / Leases / Rent to Own Account
Creditor
Original Amount
Current Balance
Monthly Payment
1
2
3
4
5
Total Debts
Complete the following information about both the Applicant and the Joint Applicant or Other Party (if applicable)
Are you obligated to make Alimony, Support or Maintenance Payments ? No Yes
If you answered "Yes", to whom (Name and Address)
Total amount per month paid
Is net income reported in part 1, (before , after ) support payment?
Are you a co maker, endorser, or guarantor on any other obligations? No Yes
If you answered "Yes", for whom and to whom
Are there any unsatisfied judgments against you? No Yes
If you answered "Yes", to whom and total outstanding
Have you been declared bankrupt in the last 10 years? No Yes
If you answered "Yes", where and when
Part 5 - Secured Credit
Complete only if credit is to be secured. Briefly describe the property to be given as security.
Names and address of all co-owners of property
If the security is real estate, give the full name of your spouse (if any)
Signatures - I certify that everything I have stated within this application and on any of the attachments is correct to the best of my knowledge. The Citizens Bank of Ashville may keep this application whether or not it is approved. By completing this online application, printing, signing, dating and returning to a local Citizens Bank of Ashville location I authorize the Citizens Bank of Ashville to check my credit and employment history and to answer questions others may ask the Citizens Bank of Ashville about my credit record with the Citizens Bank of Ashville. I understand that I must update credit information and notify the Citizens Bank of Ashville if my financial condition changes.
The Ohio Laws against discrimination require that all creditors make credit equally available to all credit worthy customers, and that credit reporting agencies maintain separate credit histories on each individual upon request. The Ohio Civil Rights Commission administers compliance with this law.
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Please review your Credit Application for completeness and accuracy. Print completed Credit Application then sign, date and return to your local Citizens Bank of Ashville office to a loan officer.
If application is approved you will be required to appear at the Citizens Bank of Ashville to sign and finalize loan documents.
