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Section 1: Certification
Note: Applicants must be domiciled in Indiana. This application is not considered complete until all required supporting documents have been received.
This application is designed to be completed by the applicant(s) and guarantor(s) with the Lender’s assistance. The party certifies that he/she/it has applied for a commercial loan from Crossroads Bank. In applying for the loan, the party provided the information within this application. The party certifies that all of the information is true and complete. The party made no misrepresentations to Crossroads Bank, nor did the party omit any important information. The party understands and agrees that Crossroads Bank may verify any information provided within the application and on subsequent documents provided to Crossroads Bank during the application process. The party fully understands that it is a federal crime punishable by fine and/or imprisonment to knowingly make any false statements when applying for a loan, as applicable under the provisions of Title 18, United States Code, Section 1014. Receipt of this application by Crossroads Bank does not constitute approval. The bank has made no representations or promises in conjunction with this application. The request will be subject to full underwriting, which may require that the party provide additional documentation. The party certifies that any additional information provided to the bank to be used for consideration of the loan requested in this application is accurate and legitimate.
Applicant Signature
Date
Section 2: Joint Intent
If this is an application for joint credit or for credit with the intention of joint personal guarantees, each person certifies that he/she intends to apply jointly.
Signature
Signature
Signature
Signature
Section 3: Request (Mark All That Apply)
Loan Type:
Term Loan
Open-end (Revolving) Line of Credit
Closed-end Line of Credit
Letter of Credit
Other, specify:
Loan Purpose:
Replenish Cash
Refinance Existing Debt
Purchase
Other, specify:
Collateral Type:
Equipment/Vehicle
Commercial Real Estate
Farm Real Estate
Residential Real Estate
Other, specify:
Collateral Offered:
Amount Requested: (required)
Term Requested:
Application Date: (required)
Section 4: Applicant and Guarantor Information
Entity #1
Name or Legal Entity Name: (required)
Intent to apply as a Borrower or Guarantor: (required)
Social Security Number or Tax Identification Number: (required)
Physical Address (if no physical, then mailing): (required)
Main Phone Number:
Cell Phone Number:
Email Address:
Driver's License Number (if applicable):
Birth Date (if applicable):
Mother's Maiden Name (if applicable):
Occupation (if applicable):
Employer & Years Employed There (if applicable):
History of bankruptcy, foreclosure, deed in lieu of foreclosure, judgment, or lawsuit in the last 7 years? (if so, state which)
Entity #2 (if applicable)
Name or Legal Entity Name:
Intent to apply as a Borrower or Guarantor:
Social Security Number or Tax Identification Number:
Physical Address (if no physical, then mailing):
Main Phone Number:
Cell Phone Number:
Email Address:
Driver's License Number (if applicable):
Birth Date (if applicable):
Mother's Maiden Name (if applicable):
Occupation (if applicable):
Employer & Years Employed There (if applicable):
History of bankruptcy, foreclosure, deed in lieu of foreclosure, judgment, or lawsuit in the last 7 years? (if so, state which)
Section 5: Information for Government Monitoring Purposes
*Attention: Do not fill out this section unless this is a dwelling related purpose. Only borrowing entities, not guarantors, are to fill out this section. The information only applies to persons applying, not business entities.
The purpose of collecting this information is to help ensure that all applicants are treated fairly and that the housing needs of communities and neighborhoods are being fulfilled. For residential mortgage lending, federal law requires that we ask applicants for their demographic information (ethnicity, sex, and race) in order to monitor our compliance with equal credit opportunity, fair housing, and home mortgage disclosure laws. You are not required to provide this information, but are encouraged to do so. The law provides that we may not discriminate on the basis of this information, or on whether you choose to provide it. However, if you choose not to provide the information and you have made this application in person, federal regulations require us to note your ethnicity, sex, and race on the basis of visual observation or surname. The law also provides that we may not discriminate on the basis of age or marital status information you provide in this application.
Instructions: You may select one or more "Hispanic or Latino" origins and one or more designations for "Race." If you do not wish to provide some or all of this infromation, select the applicable check box.
Applicant Name
Ethnicity
Hispanic or Latino
Mexican
Peurto Rican
Cuban
Other Hispanic or Latino
Not Hispanic or Latino
I do not wish to provide this information
Sex
Female
Male
I do not wish to provide this information
Race
American Indian or Alaska Native
Asian
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Black or African American
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
White
I do not wish to provide this information
Applicant Name
Ethnicity
Hispanic or Latino
Mexican
Puerto Rican
Cuban
Other Hispanic or Latino
Not Hispanic or Latino
I do not wish to provide this information
Sex
Female
Male
I do not wish to provide this information
Race
American Indian or Alaska Native
Asian
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Black or African American
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
White
I do not wish to provide this information
Section 6: Regulation B Appraisal Requirements
*Attention: Do not fill out this section unless the transaction requires an appraisal on a dwelling to be commissioned.
We may order an appraisal to determine the property’s value and charge you for this appraisal. We will promptly give you a copy of any appraisal, even if your loan does not close. You can pay for an additional appraisal for your own use at your own cost.
I acknowledge receipt of this appraisal notice. Sign here:
Section 7: Environmental Questionnaire
*Attention: This section only needs to be completed if the loan applied for will be secured by real estate. If there are multiple properties involved, please complete for all properties involved. This should be completed by the applicant.
Current use of property:
Past use(s) of property:
Has the property or any adjoining/adjacent properties use involved environmentally sensitive industries presently or in the past? (if yes, describe)
Have hazardous substances been used or identified at the property or adjoining properties in the past or present? (if yes, describe)
Are any hazardous substances, petroleum products, or chemicals stored or produced on the property or adjoining properties? (if yes, describe)
Is there evidence of contamination at the property or adjoining properties? (if yes, describe)
Are there potential sources of contamination at the property or adjoining properties (if yes, describe)
Does the applicant have any knowledge of contamination at the property or adjoining properties, or aware of any past or present legal action regarding the property or adjoining properties (if yes, describe)
Has any government entity taken any regulatory action related to environmental conditions at the property or adjoining properties? (if yes, describe)
Have any environmental risk studies (questionnaires, TSAs, Phase I, Phase II, other) or assessments been performed on the property in the past? (if yes, describe)
Is there any presence of lead paint, asbestos, or polychlorinated biphenyls on the property? (if yes, describe)
Is there any other pertinent information to the applicant’s knowledge that should be made aware to Crossroads regarding the environmental condition or safety of the property or adjoining properties? (if so, describe)
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