Member FDIC   |   Equal Housing Lender

Skip-a-Payment Request Form - FSB Mapleton
Submitter Information (Required)
First Name
Last Name
Resolve the errors marked in red before submitting again.

Privacy Policy:
Our privacy policy protects the privacy of your personal-identifying information that you provide us online.

Security Notice:
ONLY fill out this Skip-a-Payment request form on-line if you are using a browser, with the latest security enhancements. If you do not have the latest version, download it now. This form is NOT cached (saved in your computer's memory) when you QUIT your browser.

Complete this form on-line and click "Submit". Upon receipt we will send you the proper disclosures. We will also contact you to discuss your request within three business days. To safeguard your privacy, please QUIT your browser and restart it again after submitting this form. Our Skip-a-Payment Request Form is for personal loans and is NOT intended for Business use.

Loan NumberChecking Account NumberSavings Account Number

I will pay the $30.00 fee with cash or checkAuto-Debit $30.00 from my First Security Bank Checking AccountAuto-Debit $30.00 from my First Security Bank Savings Account

Customer Information
Borrower's NameSocial Security No.

Contact Phone Date of Birth

Present Address
Co-Borrower's NameSocial Security No.

Contact PhoneDate of Birth

Co-Borrower Present Address
Acknowledgement and Agreement

Each of the undersigned specifically represents to Lender and to Lender's actual or potential agents, brokers, processors, attorneys, insurers, servicers, successors and assigns and agrees and acknowledges that:

(1) the information provided in this form is true and correct as of the date set forth opposite my signature and that any intentional or negligent misrepresentation of this information contained in this form may result in civil liability, including monetary damages, to any person who may suffer any loss due to reliance upon any misrepresentation that I have made on this form, and/or in criminal penalties including, but not limited to, fine or imprisonment or both under the provisions of Title 18, United States Code, Sec. 1001, et seq.;

(2) Interest will continue to accrue through the extended period and will increase the amount of your final payment

(3) This offer is not valid for Mortgage secured loans, Commercial loans, Ag loans or Ready Reserve Credit.  Loans with balloon payments are not eligible for this offer.

(4) Account must be current to exercise the Skip-a-Payment option.  Customer must continue to make any Credit Life and A&H Insurance payments during the skipped payment months.

(5) All individuals who signed the original loan documentation must sign/e-sign the form below.

(6) my transmission of this form as an "electronic record" containing my "electronic signature," as those terms are defined in applicable federal and/or state laws (excluding audio and video recordings), or my facsimile transmission of this form containing a facsimile of my signature, shall be as effective, enforceable and valid as if a paper version of this form were delivered containing my original written signature.

To be completed and submitted by Borrowers
Borrower's NameDate

Co-Borrower's NameDate