Loan Request

Important Note: Federal law requires all financial institutions to notify applicants that they will obtain, verify and record information that identifies each person who opens an account or applies for a loan. When you open an account or apply for a loan we are required to ask your name, address, date of birth, and other information that will allow you to be identified as the account or loan applicant. In addition, we may ask for identifying documents in order to verify this information.

CD and Savings Secured loans available to First State Bank Customers
Online Personal loan requests are available to First State Bank customers and residents of Monroe County
Online Personal loan requests are available to First State Bank customers and residents of Monroe County
Application Type: Promotional Code Loan Product Customer Referred By

Loan Information

Requested Loan
Amount
Loan Purpose
Term in Months
Purchase Price
$
$
Resort Name Resort City Resort State

Collateral

New or Used? Model Year Make Model
Boat Engine (if applicable) Vehicle Mileage (if applicable) Loan Balance / Payoff Amount
(if applicable)
Will you have a trade in?
$

Collateral

Account# Current Balance
$

Applicant Information

First Name Last Name Email Housing/Residence
Type
$
Physical Address
(no P.O. boxes)
City State Zip
Primary Contact Phone Social Security # Date of Birth
() - - - -

Employment

Employment Status Your Work Title ( if retired,
your title at the time of retirement)
Name of Employer
Employer Phone Employer City Employer State
() - -
Employer ZIP/Postal Code Years and Months on Job Gross Monthly Income
$

Other Income/Other Employment

Employment Status
Your Work Title ( if retired,
your title at the time of retirement)
Name of Employer
Employer Phone Employer City Employer State
() - -
Employer ZIP/Postal Code Years and Months on Job Gross Monthly Income
$

Joint Applicant Information

First Name Last Name Email Housing/Residence
Type
Physical Address
(no P.O. boxes)
City State Zip
Phone Social Security # Date of Birth
() - - - -

Joint Employment

Employment Status Your Work Title ( if retired,
your title at the time of retirement)
Name of Employer
Employer Phone Employer City Employer State
() - -
Employer ZIP/Postal Code Years and Months on Job Gross Monthly Income
$

Other Income/Other Employment for Joint

Employment Status
Your Work Title ( if retired,
your title at the time of retirement)
Name of Employer
Employer Phone Employer City Employer State
() - -
Employer ZIP/Postal Code Years and Months on Job Gross Monthly Income
$
I/We hereby apply for the loan or credit described in the request. I/We acknowledge having read the Lender's Privacy Policy. I/We certify that I/we made no misrepresentations in this loan request or in any related documents, that all information is true and complete, and that I/we did not omit any important information. I/We agree that any property securing the loan or credit will not be used for any illegal or restricted purpose. I/We acknowledge that the Lender may verify or re-verify any information contained in this request or obtain any information or data relating to the loan, for any legitimate business purpose through any source, including a source named in this request or a consumer reporting agency. Lender may disclose to any other interested parties information as to the Lender's experiences or transactions with my/our credit. I/We understand that the Lender will retain this request and any other credit information Lender receives, even if no loan or credit is granted. These representations and authorizations extend not only to the Lender, but also to any insurer of the loan and to any investor to whom Lender may sell all or any part of the loan. I/We further authorize Lender to provide to any such insurer or investor any information or documentation that they may request with respect to my/our request, credit or loan.