Emergency Relief When You Need It Most

Emergency Relief Loan Application

Check the amount of loan requested: ❏ $1,500 ❏ $2,000 ❏ $2,500You do not have to close your loan in person! • If approved, please deposit funds to my/our account: ❏ Checking ❏ Savings

I would like to repay this loan ❏ Monthly ❏ Bi-weekly ❏ From my Checking ❏ From my Savings We intend to apply for joint credit: Primary Applicant initials Co-Applicant initials

Name Social Security # Date of Birth Savings Account #

Address Alimony, Child Support, or Separate Maintenance income need not be revealed if you do not choose to have it considered.

Cell Phone # Home Phone #

❑ Own ❏ Rent ❏ Other Monthly Payment $

Job title

Date of Hire Salary $ ❏ per month ❏ per year

Prior to Furlough/Layoff/Hours Cut

Employer/Source of Income

Work Phone #

Do you expect income to resume? If so, when?

Name Social Security # Date of Birth Savings Account #

Address Alimony, Child Support, or Separate Maintenance income need not be revealed if you do not choose to have it considered.

Cell Phone # Home Phone #

❑ Own ❏ Rent ❏ Other Monthly Payment $

Job title

Date of Hire Salary $ ❏ per month ❏ per year

Prior to Furlough/Layoff/Hours Cut

Employer/Source of Income

Work Phone #

Do you expect income to resume? If so, when?

You are entering into an Advance established under a separate Consumer Lending Plan. By signing, I/we hereby agree to the terms and conditions of this application/loan advance request. Property given as security for any other loan and/or deposits at this credit union will also secure all amounts on this loan advance subject to the limitations in our Consumer Lending Plan document. The credit union will provide or forward a copy of the Consumer Lending Plan for my/our review and acceptance. My/Our acceptance and use of the loan proceeds is my/our acknowledgment of receipt and agreement to its terms and conditions. I/We certify that all the information on this application and any attachments are true. I/We acknowledge that you will be relying on this information as a basis to extend credit. I/We understand that Section 1014, Title 18, U.S. Code makes it a federal crime to knowingly make a false statement on this application. By signing below, I/we authorize you to check my/our credit and employment history and to answer questions others may ask you about my/our credit record with you. I/We understand that this advance request is subject to approval and that once approved, you are authorized to automatically deposit loan proceeds to my/our account.

Applications with a primary and co-applicant are intended as joint loans.

X X Signature of Primary Applicant Date Signature of Co-Applicant Date

Only one Emergency Relief Loan per Member Number allowed.

P R I M A R Y A P P L I C A N T

CREDIT INFORMATION AND DISCLOSURE FOR MONTHLY PAYMENT OPTION DI

SCLO

SURE

FOR

$1,50

0 LOA

N DI

SCLO

SURE

FOR

$2,00

0 LOA

N DI

SCLO

SURE

FOR

$2,50

0 LOA

N

CREDIT INFORMATION AND DISCLOSURE FOR BI-WEEKLY PAYMENT OPTION DI

SCLO

SURE

FOR

$1,50

0 LOA

N DI

SCLO

SURE

FOR

$2,00

0 LOA

N DI

SCLO

SURE

FOR

$2,50

0 LOA

N