Financial Application

FINANCIAL APPLICATION

Applicant Information

Employment and Income

Co-Applicant (if any)

Is there a co-applicant? Check if yes. If no, leave blank.

Requested Facility

Requested Amount: $

Assets and Liabilities (Most Recent)

Please provide the current balances and estimated market values where applicable.

Credit References

Collateral and Security

Fees, Terms & Payment Instructions

Application Fee (if applicable): $ — Fees are non-refundable unless required by law.

Accepted payment methods: check the preferred methods (final method subject to lender approval). Electronic Debit Automated Clearing Check

Authorizations, Certifications and Notices

By signing below, Applicant certifies that all information provided in this application is true, complete and correct to the best of Applicant's knowledge. Applicant authorizes the lender and its agents to verify any information provided, to obtain credit reports and employment verifications, and to obtain information from banks and trade references listed herein. Applicant further authorizes any person or entity to release such information to the lender upon request.

Applicant understands and agrees that submission of this application does not constitute approval or a commitment to lend. Lender may require additional documentation, appraisals, or security prior to making any credit decision. Applicant understands that false statements may be subject to penalties under applicable law.

Applicant consents to electronic delivery of disclosures and notices where permitted by law: Check to consent.

Declarations

Has the applicant declared bankruptcy in the past seven years? If yes, explain:

Is the applicant currently party to any pending litigation that would materially affect repayment? If yes, describe:

Acknowledgment and Signature

I certify under penalty of perjury that the foregoing statements are true and correct. I acknowledge that the lender may rely on these statements in making a credit decision and that any intentional misstatement or omission may constitute fraud.

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