HE-APP-SL 2-2000

HOME EQUITY LOAN APPLICATION
PLEASE TYPE OR PRINT

IMPORTANT APPLICANT INFORMATION: 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 ACCOUNT REQUESTED

Check one to indicate the type of account you are requesting. Note: Married applicants may apply for separate accounts.
[ ] Joint Account - We intend to apply for joint credit. (initials) ________________
[ ] Individual Account - Relying solely on my income and assets.
[ ] Individual Account - Relying on my income and assets as well as income or assets of another.

INFORMATION FOR GOVERNMENT MONITORING PURPOSES

The following information is requested by the federal government for certain types of loans related to a dwelling in order to monitor the lender's compliance with equal credit opportunity, fair housing, and home mortgage disclosure laws. You are not required to furnish this information, but are encouraged to do so. You may select one or more designations for "Race." The law provides that a lender may not discriminate on the basis of this information, or on whether you choose to furnish it. However, if you choose not to furnish the information and you have made this application in person, under federal regulations this lender is required to note ethnicity, race, origin and sex on the basis of visual observation or surname. If you do not wish to furnish this information, please check below. If no proceeds from this loan will be used for home improvement, do not complete this section.

BORROWER: [ ] I do not wish to furnish this information.
Ethnicity: [ ] Hispanic or Latino        [ ] Not Hispanic or Latino
Race: [ ] American Indian or   [ ] Asian    [ ] Black or African American
               Alaska Native
          [ ] Native Hawaiian or    [ ] White
               Other Pacific Islander
Sex: [ ] Female   [ ] Male

CO-BORROWER: [ ] I do not wish to furnish this information.
Ethnicity: [ ] Hispanic or Latino        [ ] Not Hispanic or Latino
Race: [ ] American Indian or   [ ] Asian    [ ] Black or African American
               Alaska Native
          [ ] Native Hawaiian or    [ ] White
               Other Pacific Islander
Sex: [ ] Female   [ ] Male

TERMS REQUESTED

Amount

$

Length of Account Term

Periodic Payment Date

Purpose

COLLATERAL PROPERTY

Address

Year Built

Date Purchased

Present Value

Balance Owing

Title in Name(s) of:

Address of Title Holder

Name and Address of Mortgage Holder

Phone No. Acct. No.

INDIVIDUAL APPLICANT INFORMATION

Name	Birthdate	Social Security No.
Address	County	Drivers License No.

Home Phone

Business Phone

Number of Dependents

Ages of Dependents

Employer/Self Employed	Position	Years Employed	Employer's Address
Previous Employer	Position	Years Employed	Previous Employer's Address

Name and Address of Applicant's Nearest Relative

Relationship

Wages, Salary, Commissions

Gross $ /month Net $ /month

How Often Paid

Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered. Alimony, child support, separate maintenance received pursuant to: [ ] Court Order [ ] Written Agreement [ ] Oral Understanding.

Other Income: Source

Amount/Month

Marital Status [ ] Married [ ] Separated [ ] Unmarried (includes single, divorced and widowed)

JOINT APPLICANT OR OTHER PARTY INFORMATION

Provide the information in this section for a joint applicant, another party that will use or contribute assets or income toward repayment on the account, or for your spouse if you live in, or the collateral property is located in AZ, CA, ID, LA, NM, NV, TX, WA or WI.

Name	Birthdate	Social Security No.
Address	County	Drivers License No.

Home Phone

Business Phone

Number of Dependents

Ages of Dependents

Employer/Self Employed	Position	Years Employed	Employer's Address
Previous Employer	Position	Years Employed	Previous Employer's Address

Name and Address of Joint Applicant's or Other Party's Nearest Relative

Relationship

Wages, Salary, Commissions

Gross $ /month Net $ /month

How Often Paid

Other Income: Source

Amount/Month

Marital Status [ ] Married [ ] Separated [ ] Unmarried (includes single, divorced and widowed)

© Bankers Systems, Inc., St. Cloud, MN
Form HE-APP-SL 6/16/2003 Customized DETACH, COMPLETE AND RETURN. RETAIN THE DISCLOSURES AND BOOKLET FOR YOUR RECORDS.

ASSET AND DEBT INFORMATION

If "Joint Applicant or Other Party Information" section was completed above, this section should be completed giving information about both the Applicant and the Joint Applicant or Other Party. Please identify the Applicant-related information with an "*". Attach additional sheets if necessary.

ASSETS

DESCRIPTION OF ASSETS	NAME(S) OF OWNER(S)	SUBJECT TO DEBT: YES/NO	VALUE
Checking Account Number(s) (where)			$
Savings Account Number(s) (where)
Automobiles (Make, Model, Year)
Marketable Securities (Issuer, Type, No. of Shares)
Life Insurance (cash value)
Other Real Estate (Location, when acquired)
Other Assets (Describe)
Total Assets			$

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

CREDITOR	ACCOUNT NUMBER	NAME IN WHICH THE ACCOUNT IS CARRIED	ORIGINAL AMOUNT	PRESENT BALANCE	MONTHLY PAYMENTS
Landlord or Mortgage Holder on other Real Estate
Auto Loan
Auto Loan
Credit or Charge Card
Credit or Charge Card



TOTAL DEBTS			$	$	$

Credit References

1.	$	Date Paid
2.	$	Date Paid

GENERAL INFORMATION

If you or a joint applicant or other party answers "yes" to any of the following questions, please explain in the space provided.
Are you a guarantor or co-maker of any leases, contracts or debts?               [ ] Yes               [ ] No
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Are there any suits or judgments pending against you?                                   [ ] Yes               [ ] No
(Include amount) _____________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Have you been declared bankrupt in the last 10 years?                                   [ ] Yes               [ ] No
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________

New York Residents: A consumer report may be ordered in connection with your application. Upon your request, we will inform you whether or not a report was ordered. If a report was ordered we will tell you the name and address of the consumer reporting agency that provided the report. Subsequent reports may be ordered or utilized in connection with an update, renewal or extension of credit for which you have applied.
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.
     Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Married Wisconsin Residents: No provision of any marital property agreement, unilateral statement under Wisc. Statutes §766.59 or a court decree under Wisc. Statutes §766.70 adversely affects the interest of the lender unless the lender, prior to the time the credit is granted, is furnished a copy of the agreement, statement or decree or has actual knowledge of the adverse provision when the obligation to the lender is incurred.

I certify that everything I have stated in this application and on any attachments is correct. Lender may keep this application whether or not it is approved. By signing below I authorize Lender to check my credit and employment history and to answer questions others may ask Lender about my credit record with Lender. I understand that I must update this credit information at Lender's request and if my financial condition changes.
I acknowledge receipt of the Home Equity Brochure and the lender's Home Equity disclosure statement on today's date.

Applicant X ______________________________ Date __________ Joint-Applicant X ______________________________ Date __________

CREDITOR USE ONLY

This application was taken by: [ ] face to face interview [ ] mail [ ] telephone [ ] internet

Date Application Received:	Received By:	Amount Requested $
Approved By:	Approved By:	Amount Approved $
Rescindable? [ ] Yes [ ] No	Funding Date:	Initial Advance $