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STATEMENT OF INDEBTEDNESS AND LIABILITIES FOR WHICH YOU ARE OBLIGATED IN ANY MANNER Creditor Name Account Amt Bal Savings Acct at Checking Acct at Stocks/Bonds Have you ever filed for bankruptcy Shares No Your Estimated Net Worth If YES why Date Filed This form may be emailed to lsfcu att. LAKESIDE FEDERAL CREDIT UNION APPLICATION FOR CREDIT - PDF VERSION Type of Credit Check one DATE Open-end credit line-of-credit or special loan plan* REFINANCED AMOUNT Closed-end Loan* MEMBER ACCT Co-signer. NOTE Credit Life Insurance. Amt. Requested Purpose of loan Credit Disability Ins* Full Name Date of Birth Address SSN City Phone Yrs at this residence State No* of Dependents Previous Address ZIP Driver Lic No* Employed by How Long Yrs Take home pay is Weekly Bi-weekly Previous Employer Monthly Position Years Take Home Pay Semi-monthly Copy of the most recent check stub is required* Monthly Income OTHER INCOME Source Date Source Began Amount Monthly ALIMONY CHILD SUPPORT OR MAINTENANCE INCOME Note You need not disclose the following sources of income but if you want the credit union to consider such income in connection with this loan application please complete the following Alimony Child Support Person Liable Maintenance Ages of Children Income received is pursuant to a written agreement. court decree. Are payment up-to-date Yes. No* Nearest Relative not living with you Relationship YOUR HOME Tel Own* Rent. Buying. Landlord/Mortgage Holder State ZIP Name in which Titled Value Balance Mo. Pmt Insurance Agent s Name Address. Phone This is page 1 of a two-page form* The second page must be completed to be properly submitted* ELECTRONIC APPLICATION FOR CREDIT Automobile Information Make of Auto Titled to Financed by Auto Insurance Name Address Phone. net. You may also print it locally and mail it to Lakeside Federal Credit Union 7020 Indianapolis Boulevard Hammond Indiana 46324 or Fax it to 219-845-7260. By signing this form you are swearing/affirming under penalties of perjury that all information contained herein is true and accurate. You further authorize a check of your credit and employment history from time-to-time as we deem necessary and to answer questions from others about your credit experience with us. Applicant s Signature Date If you are e-mailing this form indicate your Signature by checking this box. To e-mail this form save it to a file name and attach it to a note to Lakeside Federal at the above e-mail address. Be advised that e-mail is not secure. SUBMIT PROOF OF INCOME BY MAIL OR IN PERSON AT OUR OFFICE* Thank you. LAKESIDE FEDERAL CREDIT UNION APPLICATION FOR CREDIT - PDF VERSION Type of Credit Check one DATE Open-end credit line-of-credit or special loan plan* REFINANCED AMOUNT Closed-end Loan* MEMBER ACCT Co-signer. NOTE Credit Life Insurance. Amt. Requested Purpose of loan Credit Disability Ins* Full Name Date of Birth Address SSN City Phone Yrs at this residence State No* of Dependents Previous Address ZIP Driver Lic No* Employed by How Long Yrs Take home pay is Weekly Bi-weekly Previous Employer Monthly Position Years Take Home Pay Semi-monthly Copy of the most recent check stub is required* Monthly Income OTHER INCOME Source Date Source Began Amount Monthly ALIMONY CHILD SUPPORT OR MAINTENANCE INCOME Note You need not disclose the following sources of income but if you want the credit union to consider such income in connection with this loan application please complete the following Alimony Child Support Person Liable Maintenance Ages of Children Income received is pursuant to a written agreement.

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