Lapeer County School Employees Credit Union

168 N. Saginaw St, PO Box 425, Lapeer, MI 48446

To be completed by applicants, cosigners and guarantors for Revolving Credit and Line of Credit Plans and cosigner and guarantors for Closed-End Loans. Use also for periodic update of information.

Date

Single Married Separated Drivers License No.

NameBirth DateSocial Sec #

AddressCity_______________State______Zip____________

Years thereTelephone #Number of Dependents

Previous AddressCityStateZipYrs there

EMPLOYMENT

Employed byDate Employed

PositionMonthly income Telephone

Complete Business Address

Previous EmployerAddress

PositionYrs. there Monthly income $

OTHER INCOME

**Exclude alimony, child support and separate maintenance payments

Source Amount $

If you are relying on the income of you spouse or another person as a basis for repayment, complete the following:

Name Social Security# 

Employed by Date EmployedMonthly income

You are not required to discloses income from alimony, child support or separate maintenance but if you want it considered in connection with this application, complete the following:

Payor Amount $

Alimony Child Support Separate Maintenance

How long have payments been made?Are payments up to date?

STATEMENT OF TOTAL INDEBTEDNESS AND LIABILITIES

THIS SECTION MUST BE ANSWERED

Creditor	CREDITORS NAME	PRESENT BALANCE	MONTHLY PAYMENT	PAST DUE Yes or No
Rent
Mortgage
Auto Loan
Auto Loan
Credit Card
Other
Other
Other

Additional Debts-Inital Correct Box I have no other debts Additional listing of debts is attached

Share draft or checking account No.Where?

Share or Savings Account No.Where?

1. Make of AutoYear

2. Make of AutoYear

Are you a cosigner or guarantor on any other loans? Yes No

How Much? For whom?

Have you taken bankruptcy within the past 10 years?Yes No

Are there any unsatisfied judgements against you? Yes No

Everything that I have stated in this application is correct to the best of my knowledge and is stated for the purpose of obtaining credit from the credit union.

Signature_______________________________Date