HealthCare United FCU Loan Application
Please print this form, fill it out and fax to 410-828-7525
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General Information:

Will you be applying for Individual or Joint Credit: Joint Individual

If applying for joint credit, please sign below to verify that you intend to apply for joint credit

Applicant:

Co-Applicant:

Marital Status: Complete marital status if this loan is for:
 a. Joint or secured credit, or
 b. You reside in or rely on property located in a Community Property State. (AZ, CA, ID, LA, NM, NV, TX, WA, WI)
  Unmarried
  Married
  Separated
  This loan is not for joint or secured credit and I do not live in the states listed above.

Type of Loan Requested:

Loan Amount Requested:

Loan Term Requested:

Primary Applicant:

Last Name:

Member Number:

First Name:

Middle Name:

Social Security Number (TIN):

Date of Birth:

Number of Dependents:

Ages of Dependents:

Home Phone Number:

Work Phone Number:

Other Phone Number:

Email Address:

Drivers License #:

Drivers License State:

Address 1:

Address 2:

City:

State, Zip:

Time at Current Residence:

Residence Type: Rent Own Other:

Monthly Payment:

Address 1:

Address 2:

City:

State, Zip:

Time at Previous Residence:

Residence Type: Rent Own Other:

Name:

Phone Number:

Employment Status: Full Time Part Time Temp Retired Other (please specify):

Job Title:

Job Start Date:

Gross Salary:

per Year Month Hour

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.

Other Income:

per Year Month Hour

Other Income Source:

Name:

Phone Number:

Employment Status: Full Time Part Time Temp Retired Other (please specify):

Job Title:

Job Start Date:

Job End Date:

Gross Salary:

per Year Month Hour

Co-Applicant:

Last Name:

Member Number:

First Name:

Middle Name:

Social Security Number (TIN):

Date of Birth:

Number of Dependents:

Ages of Dependents:

Home Phone Number:

Work Phone Number:

Other Phone Number:

Email Address:

Drivers License #:

Drivers License State:

Address 1:

Address 2:

City:

State, Zip:

Time at Current Residence:

Residence Type: Rent Own Other:

Monthly Payment:

Address 1:

Address 2:

City:

State, Zip:

Time at Previous Residence:

Residence Type: Rent Own Other:

Name:

Phone Number:

Employment Status: Full Time Part Time Temp Retired Other (please specify):

Job Title:

Job Start Date:

Gross Salary:

per Year Month Hour

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.

Other Income:

per Year Month Hour

Other Income Source:

Name:

Phone Number:

Employment Status: Full Time Part Time Temp Retired Other (please specify):

Job Title:

Job Start Date:

Job End Date:

Gross Salary:

per Year Month Hour

References

Last Name:

First Name:

Relationship:

Phone Number:

Address 1:

Address 2:

City:

State, Zip:

Debts/Monthly Payments:

List all other debts (for example, auto loans, credit cards, second mortgage, home assoc. dues, alimony, child support,
 child care, medical, utilities, auto insurance, IRS liabilities, etc.) Please use a separate line for each credit card and auto loan.

Debt

Monthly Payment 

Debt

Monthly Payment 

Additional Information

How would you prefer to be contacted?
  Home Phone
  Work Phone
  Other Phone
  Email Address
  Other:

Special Instructions/Comments:
 
 
 

Signatures

Income verification is required; other information may be required.

I certify that statements on this application are true and complete. I authorize any person, association, firm or corporation to furnish, on request of this Financial Institution, information concerning me or my affairs.(Sec. 1014, Title 18, U.S. Code makes it a Federal Crime to knowingly make a false statement on this application.)

Primary Signature:

Date:        

Joint Owner Signature:

Date: