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|$ Amount Applying For||No. of Months||Collateral (Home, Land, Auto, Unsecured, etc.)|
|Borrower's Name||Social Security No.||Contact Phone|
|Co-Borrower's Name||Social Security No.||Contact Phone|
|Borrower $||Co - Borrower $||Total $|
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) the loan requested pursuant to this form (the "Loan") will be secured by the collateral described herein;
(3) the collateral will not be used for any illegal or prohibited purpose or use;
(4) all statements made in this form are made for the purpose of obtaining a loan;
(5) any owner or servicer of the Loan may verify or reverify any information contained in the form from any source named in this form, and Lender, its successors or assigns may retain the original and/or an electronic record of this form, even if the Loan is not approved;
(6) the Lender and its agents, brokers, insurers, servicers, successors and assigns may continuously rely on the information contained in the form, and I am obligated to amend and/or supplement the information provided in this form if any of the material facts that I have represented herein should change prior to closing of the Loan;
(7) in the event that my payments on the Loan become delinquent, the owner or servicer of the Loan may, in addition to any other rights and remedies that it may have relating to such delinquency, report my name and account information to one or more consumer credit reporting agencies;
(8) ownership of the Loan and/or administration of the Loan account may be transferred with such notice as may be required by law;
(9) neither Lender nor its agents, brokers, insurers, servicers, successors or assigns has made any representation or warranty, express or implied, to me regarding the collateral or the condition or value of the collateral; and
(10) 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.
I understand that you will retain this form whether or not it is approved. You are authorized to check my/our credit and employment history and to answer questions about your credit experience with me/us.
|Borrower's Name||Date||Co - Borrower's Name||Date|