Credit Application Citizens National Bank at Brownwood

IMPORTANT APPLICANT INFORMATOIN: Federal law requires financial institutions to obtain sufficient information to verify your identity. you may be asked several questions and to provide one or more forms of identification to fulfill this requirement. In some instances we may use outside sources to confirm the information. The information you provide is protected by our privacy policy and federal law.

Type of Credit Requested(Required)

Secured

Unsecured

Individual Credit - relying on my income or assets.

Individual Credit - relying on my income or assets as well as income or assets from other sources.

Joint Credit - We intend to apply for joint credit.

Citizens National Bank

P.O. Box 1629

Brownwood, TX 76804

Date of Application(Required)

Amount Requested(Required)

How Long(Required)

Payment Date Desired(Required)

Want to Repay

Monthly

Other

Purpose

Account Number

SECTION A - INDIVIDUAL APPLICANT INFORMATION

Name(Required)

First Middle Last

Birth Date

Phone(Required)

Social Security Number(Required)

Drivers License Number

Present Address(Required)

Street Address Address Line 2 City State ZIP Code

How Long(Required)

Previous Address

Street Address Address Line 2 City State ZIP Code

How Long

Have you applied for credit with us before?(Required)

Yes

If Yes, when?

Number of Dependants

Dependant Ages

Name of Nearest Relative Not Living With You

First Last

Relationship

Address

Street Address Address Line 2 City State ZIP Code

Phone

Employer

Employer Address

Street Address Address Line 2 City State ZIP Code

How Long

Business Phone

Position/Title

How Often Paid?

Take Home Salary Per Month

Previous Employer

Address

Street Address Address Line 2 City State ZIP Code

How Long

Alimony, child support, sperate maintenance received under:

Court Order

Written Agfreement

Oral Understanding

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.

Sources of Other Income

Amount Per Month

Section B - JOINT APPLICANT OR OTHER PARTY INFORMATION

Name

First Middle Last

Birth Date

Phone

Social Security Number

Present Address

Street Address Address Line 2 City State ZIP Code

How Long

Previous Address

Street Address Address Line 2 City State ZIP Code

How Long

Have you applied for credit with us before?

Yes

If Yes, when?

Number of Dependants

Dependant Ages

Name of Nearest Relative Not Living With You

First Last

Relationship

Address

Street Address Address Line 2 City State ZIP Code

Phone

Employer

Employer Address

Street Address Address Line 2 City State ZIP Code

How Long

Business Phone

Position/Title

How Often Paid?

Take Home Salary Per Month

Previous Employer

Address

Street Address Address Line 2 City State ZIP Code

How Long

Alimony, child support, sperate maintenance received under:

Court Order

Written Agfreement

Oral Understanding

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.

Sources of Other Income

Amount Per Month

Section C - MARITAL STATUS

Complete only if: for joint or secure credit, or applicant resides in a community property state or is relying on property located in such a state. (*includes single, divorced and widowed)

Applicant

Married

Separated

Unmarried*

Other Party

Married

Separated

Unmarried*

Section D - ASSET & DEBT INFORMATION

If Section B has been completed, this Section should be completed giving information about both the Applicant and Joint Applicant or Other Person. Please mark Applicant-related information with an "A." if Section B was not completed, only give information about the Applicant in this Section.

Checking Account Number(s) / (where)

Value

Savings Account Number(s) / (where)

Value

Other Assets (describe)

Value

TOTAL:

OUTSTANDING DEBTS (Include charge accounts, installment contracts, credit cards, rent, mortgages and other obligations.)

Creditor / Account Number / Name the Account is Under:

Landlord or Mortgage Holder, Automobile (make, model, year), Etc...

Original Amount

(OMIT RENT)

Present Balance

(OMIT RENT)

Monthly Payment

Creditor / Account Number / Name the Account is Under:

Landlord or Mortgage Holder, Automobile (make, model, year), Etc...

Original Amount

(OMIT RENT)

Present Balance

(OMIT RENT)

Monthly Payment

Creditor / Account Number / Name the Account is Under:

Landlord or Mortgage Holder, Automobile (make, model, year), Etc...

Original Amount

(OMIT RENT)

Present Balance

(OMIT RENT)

Monthly Payment

Creditor / Account Number / Name the Account is Under:

Landlord or Mortgage Holder, Automobile (make, model, year), Etc...

Original Amount

(OMIT RENT)

Present Balance

(OMIT RENT)

Monthly Payment

Creditor / Account Number / Name the Account is Under:

Landlord or Mortgage Holder, Automobile (make, model, year), Etc...

Original Amount

(OMIT RENT)

Present Balance

(OMIT RENT)

Monthly Payment

Creditor / Account Number / Name the Account is Under:

Landlord or Mortgage Holder, Automobile (make, model, year), Etc...

Original Amount

(OMIT RENT)

Present Balance

(OMIT RENT)

Monthly Payment

Creditor / Account Number / Name the Account is Under:

Landlord or Mortgage Holder, Automobile (make, model, year), Etc...

Original Amount

(OMIT RENT)

Present Balance

(OMIT RENT)

Monthly Payment

Creditor / Account Number / Name the Account is Under:

Landlord or Mortgage Holder, Automobile (make, model, year), Etc...

Original Amount

(OMIT RENT)

Present Balance

(OMIT RENT)

Monthly Payment

Totals:

Original Amount (TOTAL)

Present Balance (TOTAL)

Monthly Payment (TOTAL)

Complete the following information about both the Applicant and Joint Applicant or Other Person (if applicable):

Are you obligated to make Alimony, Support or Maintenance Payments?

Yes

If yes, to (Name & Address)

Amount Per Month

Are you a comaker, endorser, or guarantor on any loan or contract?

Yes

If yes, for whom?

To whom?

Are there any unsatisfied judgments against you?

Yes

If yes, to whom owed?

Amount

Have you been declared bankrupt in the last 10 years?

Yes

If yes, where?

Year?

Section E - SECURED CREDIT

Complete only if credit is to be secured. Briefly describe the property to be given as security and indicate if others have an ownership interest.

Property Description:

Names & Addresses of all co-owners of the porperty:

If the security is real estate, give the full name of your spouse (if any):

Signatures

Applicant Name(Required)

First Last

Date

Other Applicant Name

First Last

Date

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