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Loan Application

Florida Parishes Bank Secure Loan Application
Florida Parishes Bank applications are private and secure.

Please provide all the requested information. When you have completed the form, press the Submit button to send your application. If necessary, we will contact you for additional information.

The items marked with (*) are required fields.


General Information

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

(If Joint, the co-applicant section has the same required fields as the primary 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 application is not for joint or secured credit and I do not live in the states listed above.

*Loan Amount Requested

$

*Property Value

$

*Current Mortgage Balance

$

*Current Monthly Mortgage Payment

$

Second Mortgage Balance (if applicable)

$

Intended Purpose of Loan

If the intended purpose is debt consolidation, please list creditors to be paid with loan proceeds:

Creditor Account Number Balance
$
$
$

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Primary Applicant

*Do you have an account with us?

Yes No
*Last Name
*First Name
Middle Name
*Social Security Number (TIN) --
*Date of Birth //
Number of Dependents
Ages of Dependents
*Home Phone Number --
Work Phone Number - - ext.
Number - -ext.
Email Address
Drivers License #
Drivers License State

Home Address

*Address 1
Address 2
*City
*State *Zip -
Time at Current Residence
Years Months
Residence Type Own Rent Other

Previous Address

Address 1
Address 2
City
State Zip -
Time at Previous Residence
Years Months
Residence Type: Own Rent Other

Present Employer

Name
Phone Number - - ext.
Employment Status
Full Time
Part Time
Temp
Retired
Other
Job Title
Job Start Date //
Gross Salary
$ Per

Alimony, child support, or separate maintenance need not be revealed if you do not wish to have it considered as a basis for repaying obligation.

Other Income
$ Per
Other Income Source

Previous Employer

Name
Phone Number - - ext.
Employment Status
Full Time
Part Time
Temp
Retired
Other
Job Title
Job Start Date //
Job End Date //
Gross Salary $ Per

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Co-Applicant

*Do you have an account with us?
Yes No
*Last Name
*First Name
Middle Name
*Social Security Number (TIN) --
*Date of Birth /
Number of Dependents
Ages of Dependents
*Home Phone Number --
Work Phone Number -- ext.
Number - -ext.
Email Address
Drivers License #
Drivers License State

Home Address

*Address 1
Address 2
*City
*State *Zip -
Time at Current Residence
Years Months
Residence Type
Own Rent Other
Monthly Payment
$

Previous Address

Address 1
Address 2
City
State
Zip -
Time at Previous Residence
Years Months
Residence Type Own Rent Other

Present Employer

Name
Phone Number -- ext.
Employment Status Full Time Part Time Temp Retired Other
Job Title
Job Start Date //
Gross Salary $ Per

Alimony, child support, or separate maintenance need not be revealed if you do not wish to have it considered as a basis for repaying obligation.

Other Income $ Per
Other Income Source

Previous Employer

Name
Phone Number -- ext.
Employment Status
Full Time Part Time Temp Retired Other
Job Title
Job Start Date //
Job End Date //
Gross Salary $ Per

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References

Nearest relative Not Living With You

Last Name
First Name
Relationship
Number -- ext.
Address 1
Address 2
City
State
Zip

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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.

Debts Monthly Payments










$
$
$
$
$
$
$
$
$
$
$

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Additional Information

How would you prefer to be contacted?
Home Phone
Work Phone
Cell Phone
Email Address
Other
Please add me to your email list.
Special Instructions/Comments

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CREDIT APPLICATION INSURANCE DISCLOSURE

You have applied for a loan with Lender.  In connection with your application, Lender may solicit, offer or sell you an insurance product or annuity.  This notice is given to advise you of information related to any insurance product or annuity that is offered, solicited or sold in connection with your loan application and available on a voluntary basis through the Lender.

THE PURCHASE OF ANY INSURANCE PRODUCT OR ANNUITY THROUGH THE LENDER IN CONNECTION WITH AN EXTENSION OF CREDIT IS NOT REQUIRED.  IT IS STRICTLY VOLUNTARY AND IS NOT A FACTOR IN OBTAINING CREDIT, FOR EXAMPLE:

THE LENDER MAY NOT CONDITION A LOAN OR OTHER EXTENSION OF CREDIT ON EITHER:

      1.     YOUR PURCHASE OF AN INSURANCE PRODUCT OR ANNUITY FROM THE LENDER OR ANY OF ITS
               AFFILIATES, OR

      2.     YOUR AGREEMENT NOT TO OBTAIN, OR PROHIBITION BY US AGAINST YOU OBTAINING AN INSURANCE
              PRODUCT OR ANNUTITY  FROM AN ENTITY NOT AFFILIATED WITH THE LENDER.

By submitting this document, you acknowledge that you have read the above disclosure contained in this notice and that you have been furnished with a copy of this notice and understand its terms.

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.)

Security Code (Not Case Sensitive)