Loan Application - fax to 412-653-5076

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:
Home Address
Address 1:
Address 2:
City:	State, Zip:
Time at Current Residence:	Residence Type: Rent Own Other:
Monthly Payment:
Previous Address
Address 1:
Address 2:
City:	State, Zip:
Time at Previous Residence:	Residence Type: Rent Own Other:
Present Employer
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:
Previous Employer
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:
Home Address
Address 1:
Address 2:
City:	State, Zip:
Time at Current Residence:	Residence Type: Rent Own Other:
Monthly Payment:
Previous Address
Address 1:
Address 2:
City:	State, Zip:
Time at Previous Residence:	Residence Type: Rent Own Other:
Present Employer
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:
Previous Employer
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
Nearest Relative Not Living With You
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.) In order to comply with the U.S.A. Patriot Act, the United Community Federal Credit Union is required to verify the identity the members applying for and opening new accounts/services or adding signatories to existing accounts/services with the credit union. Information that we are required to obtain includes:Name Mailing Address Residence Address (if different) Social Security Number or Tax Identification Number Date of Birth Copy of government issued photo ID (such as driver's license, passport, Student ID, State issued ID, etc.) Additional data or identification, as required under the U.S.A. Patriot Act, may also be gathered depending on the type of account applied for or opened. Data on existing members will be gathered as they open or use additional services offered by the credit union or add signatories on accounts. The U.S.A. Patriot Act requires the credit union to maintain records of the identification verification and update the information. Confidentiality of this information will be maintained as required under the Privacy Act and all other applicable laws and regulations.
Primary Signature:	Date:
Joint Owner Signature:	Date:

	Loan Application Please print this form, fill it out and fax to 412-653-5076