LOANLINER®

LOAN REQUEST

Clara Barton FCU, 2025 E Street, NW, LL1,
Washington, DC  20006

Married applicants may apply for a separate account. If you are applying for Individual Credit, you must complete the Applicant section about yourself and the Co-Applicant section about your spouse if:

  1. You live in or the property pledged as collateral is located in a community property state (AZ, CA, ID, LA, NM, NV, TX, WA, WI),
  2. Your spouse will use the account, or
  3. You are relying on your spouse's income as a basis for repayment.

If you are relying on income from alimony, child support or separate maintenance, complete the Co-Applicant section to the extent possible about the person on whose payments you are relying.

If you are applying for Joint Credit with another person, complete the Applicant and Co-Applicant sections. If you are a Wisconsin resident and are applying for Joint Credit with someone other than your spouse, each of you should complete the Applicant section of separate applications. If either or both of you are married, you must also provide information about your spouse and complete the Signature area at the end of this application.

TYPE AND AMOUNT OF CREDIT YOU'RE REQUESTING

Is this your first loan from us? yes no
Amount/Credit Limit Requested: $
Approximate Time to Repay: How Many? Periods:
Loan Type:
Security Offered:
(for secured credit only, not applicable to credit cards)
Type of Credit: Individual Joint

For Credit Cards, see Disclosure Table

PAYMENT PROTECTION COVERAGE Check if desired

Find out more about Payment Protection Insurance and why it's a better consumer value when offered through your credit union.

Check coverage(s) desired. We will disclose the cost of this Payment Protection Insurance - Credit Disability and Credit Life - to you. A separate enrollment form which discloses the terms and conditions must be signed for coverage to become effective.

Yes No Do you want your loan protected for you and your family if you become disabled?
Yes No Do you want your loan protected for you and your family in the event of your death?

TELL US ABOUT YOURSELF

Applicant Co-Applicant
Name: Name:
CU Account #: CU Account #:
Social Security #: Social Security #:
Please indicate your marital status if you are applying for Joint Credit, secured credit or if you live in a community property state:
Married Separated Unmarried (Single - Divorced - Widowed)		 Please indicate your marital status if you are applying for Joint Credit, secured credit or if you live in a community property state:
Married Separated Unmarried (Single - Divorced - Widowed)
Driver's License #:
State: Credit union account # 		Driver's License #:
State: Credit union account #
Birth Date:
Place of Birth 		Birth Date:
Place of Birth
Home Phone:
Business Phone: 		Home Phone:
Business Phone:
Present Address:
Years There: Own Rent		 Present Address:
Years There: Own Rent
Job Title: Job Title:
ETS Date: ETS Date:
DEBTS DEBTS
Mortgage/Rent owed to: Mortgage/Rent owed to:
Balance (Mortgage only): Balance (Mortgage only):
Monthly Payment:
Current APR % (Mortgage only): 		Monthly Payment:
Current APR % (Mortgage only):
Person Responsible for Payment: Person Responsible for Payment:
INCOME INCOME
Employer: Employer:
Income: $ Net Gross
Annual Monthly Bi-weekly Weekly		 Income: $ Net Gross
Annual Monthly Bi-weekly Weekly
Other Income: (Notice: Alimony,child support or separate maintenance income need not be revealed if you do not have it considered as a basis for repaying this obligation.)
Source:
$ Annual MonthlyHourly		 Other Income: (Notice: Alimony,child support or separate maintenance income need not be revealed if you do not have it considered as a basis for repaying this obligation.)
Source:
$ Annual MonthlyHourly

CREDIT CARD DISCLOSURES

Disclosure Table for (CU credit card)
Annual percentage rate for purchases 11.90% (effective 4/1/03)
Grace period for repayment of the balance for purchases Minimum 25 days from statement date
Method of computing the balance for purchases Average daily balance including new purchases
Annual fees None
Minimum finance charge None
Transaction fee for purchases None

Transaction fee for cash advances: $0  Late-payment fee: $10  Over-the-credit-limit fee: $10
This information is accurate as of April 1, 2003 and is subject to change after that date. Please contact the credit union at (703) 206-6118 for any changes to this information.

PLEDGE OF SHARES FOR CREDIT CARDS: By submitting this application, you grant us a security interest in the following accounts to secure your credit card agreement. You authorize us to apply the balance in these accounts to any amounts due under these agreements if you should default. If no dollar amount or account number is indicated below, you authorize us to apply any balance in your account at the time of default to pay any amounts due under these agreements. Shares and deposits in an Individual Retirement Account and any other account that would lose special tax treatment under state or federal law if given as a security are not subject to the security interest you have given in your shares and deposits.

Amount $ Account # Amount $ Account #

NOTICE TO OHIO RESIDENTS: The Ohio laws against discrimination require 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.

NOTICE TO WISCONSIN RESIDENTS: No provision of any marital property agreement, unilateral statement under S.766.59, or court decree under S.766.70 will adversely affect the rights of the credit union unless the credit union is furnished a copy of the agreement, statement or decree, or has actual knowledge of its terms, before the credit is granted or the account is opened.

If you are applying for this account or loan with someone other than your spouse, you agree by signing below that the credit applied for, if granted, will be incurred in the interest of the marriage or family.

____________________
Borrower Signature and Date

SIGNATURES: You promise that everything you have stated in this request is correct to the best of your knowledge. If there are any important changes, you will notify us in writing immediately. You also agree to notify us of any change in your name, address or employment within a reasonable time thereafter. You authorize the credit union to obtain credit reports in connection with this request. If you request, the credit union will tell you the name and address of any credit bureau from which it received a credit report on you. You understand that it is a federal crime to willfully and deliberately provide incomplete or incorrect information on requests made to Federal Credit Unions or State Chartered Credit Unions insured by the NCUA. You understand that the credit union will rely on the information in the request and your credit report to make its decision. By signing below, you agree to the terms of the Credit Card Agreement which will be sent with the card and you agree to pay all charges incurred in accordance with the terms of that Agreement.

X________________________________
Applicant Signature and Date		 X________________________________
Co-Applicant Signature and Date

By submitting this loan request, you agree that the information is correct to the best of your knowledge. You also agree to notify us of any changes to your name, address or employment.

You authorize the credit union to obtain credit reports in connection with this request.

 

©CUNA MUTUAL INSURANCE SOCIETY, 1980, 82, 84, 86, 89. ALL RIGHTS RESERVED CSTLR1 6857 - Internet Loan Request

After completing this form, for security reasons, please print it and mail it to us at 2025 E St. NW, LL1, Washington, DC, 20006 along with a current paystub or fax it to us at 202-303-0136.