Equal Housing Lender | Member FDIC
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Small Dollar Loan Form
Submitter Information
First Name (required)
Last Name (required)
upload instructions Follow these instructions to upload files.

  1. Click upload button example to select a file for upload. For large files, this process may take a couple of minutes.

  2. If you accidentally select the wrong file, click the red "DELETE FILE" next to its name to remove it.

  3. Your files will be attached to this form when submitting.

  4. Allowed File Types: JPG, JPEG, GIF, PDF, PNG, SVG, TIF, TIFF, TXT, Office Docs (Word, Excel, PowerPoint).

IF YOU ARE UPLOADING FROM A MOBILE BROWSER, please select an existing file on your device, rather than attempting to upload files directly from the Camera app.

Resolve the errors marked in red before submitting again.
Amount Requested (required)
Click on the dropdown menu to select an amount between $1,000 and $2,500
 
 
Loan Purpose (required)
Check all that apply
Borrower's NameSocial Security No.Date of Birth

 
Cell PhoneHome PhoneE-mail address

 
Driver's License NumberDriver's License StateDriver's License Expiration DateDriver's License Date of Issue

 
Present Address (required)
No. of years at current addressNo. of dependentsMonthly Rent of Mortgage Payment ($)

 
Employer NameEmployer AddressNo. of Years With Current EmployerPosition

 
Gross Monthly Income ($)

 
Have you ever filed bankruptcy?Have you had any judgements against you?
Yes
 
No
 
Bank Account Information for Deposit of Loan Proceeds
Bank NameAccount Holder NameBank Account NumberBank Routing Number

 
Bank Account Information for Automatic Draft of Loan Payments
(if different from the deposit account)
Bank NameAccount Holder NameBank Account NumberBank Routing Number

 
Please upload a copy of your identification
(e.g., driver's license, GA ID, Passport, Military ID)
Please upload proof of income
(e.g., recent pay stub, 1099, verification letter of SSA, VA, retirement (if applicable), bank account statement showing direct deposit (if applicable)
Borrower's NameDate

 
(required)