Application
A table that includes required credit card disclosures is on a separate document
provided with this Application. To obtain any change in the required information
since it was printed, write to us at the address stated on this Application.
Married Applicants: May apply for a separate account.
Individual Credit: You must complete the Applicant section about yourself and the Other section about your spouse if:
1. you live in or the property pledged as collateral is located in a community property state (AK, AZ, CA, ID, LA, NM, NV, TX, WA, WI),
2. your spouse will use the account, or
3. you are relying on your spouse's income as a basis for repayment. If you are relying on income from alimony, child support, or separate maintenance,
complete the Other section to the extent possible about the person on whose payments you are relying.
Joint Credit: Each Applicant must individually complete the appropriate section below. If Co-Borrower is spouse of the Applicant, mark the Co-Applicant
box.
Guarantor: Complete the Other section if you are a guarantor on an account/loan.
Credit Card Account:
Individual
Joint
Individual
Joint
LOANLINER Account/Loan:
(Including ATM/Debit Card Access to the Account if Available)
Credit Limit Requested $
Amount Requested $
If Authorized User, Name:
Purpose/Collateral:
Repayment:
Payroll Deduction
Cash
Military Allotment
Automatic Payment
PAYMENT PROTECTION
Yes
No
Are you interested in having your loan protected?
If you answer "yes", the credit union will disclose the cost to protect your loan. The protection is
voluntary and does not affect your loan approval. In order for your loan to be covered, you will need to
sign a separate application that explains the terms and conditions.
APPLICANT
OTHER
NAME
NAME
ACCOUNT NUMBER
ACCOUNT NUMBER
CO-APPLICANT
SPOUSE
OTHER
SOCIAL SECURITY NUMBER
DRIVER'S LICENSE NUMBER/STATE
SOCIAL SECURITY NUMBER
DRIVER'S LICENSE NUMBER/STATE
AGES OF DEPENDENTS
EMAIL ADDRESS
AGES OF DEPENDENTS
EMAIL ADDRESS
BIRTH DATE
HOME PHONE
BUSINESS PHONE/EXT.
PRESENT ADDRESS (Street - City - State - Zip)
OWN
BIRTH DATE
HOME PHONE
BUSINESS PHONE/EXT.
PRESENT ADDRESS (Street - City - State - Zip)
RENT
OWN
RENT
LENGTH AT RESIDENCE
LENGTH AT RESIDENCE
PREVIOUS ADDRESS (Street - City - State - Zip)
OWN
PREVIOUS ADDRESS (Street - City - State - Zip)
RENT
OWN
LENGTH AT RESIDENCE
COMPLETE FOR JOINT CREDIT, SECURED CREDIT OR IF YOU LIVE IN A COMMUNITY
PROPERTY STATE:
MARRIED
SEPARATED
COMPLETE FOR JOINT CREDIT, SECURED CREDIT OR IF YOU LIVE IN A COMMUNITY
PROPERTY STATE:
UNMARRIED (Single - Divorced - Widowed)
MARRIED
SEPARATED
EMPLOYMENT/INCOME
EMPLOYMENT/INCOME
NAME AND
ADDRESS OF
EMPLOYER
NAME AND
ADDRESS OF
EMPLOYER
TITLE/GRADE
START DATE
SUPERVISOR'S NAME
IF SELF EMPLOYED, TYPE OF BUSINESS
RENT
LENGTH AT RESIDENCE
HOURS AT WORK
UNMARRIED (Single - Divorced - Widowed)
TITLE/GRADE
START DATE
HOURS AT WORK
SUPERVISOR'S NAME
IF SELF EMPLOYED, TYPE OF BUSINESS
NOTICE: ALIMONY, CHILD SUPPORT, OR SEPARATE MAINTENANCE INCOME NEED NOT BE
REVEALED IF YOU DO NOT CHOOSE TO HAVE IT CONSIDERED.
NOTICE: ALIMONY, CHILD SUPPORT, OR SEPARATE MAINTENANCE INCOME NEED NOT BE
REVEALED IF YOU DO NOT CHOOSE TO HAVE IT CONSIDERED.
EMPLOYMENT INCOME
EMPLOYMENT INCOME
OTHER INCOME
$_____________ Per _____________
$_____________ Per _______________
OTHER INCOME
$_____________ Per ______________ $_____________ Per ______________
NET
GROSS
SOURCE
NET
YES
MILITARY: IS DUTY STATION TRANSFER EXPECTED DURING NEXT YEAR?
WHERE
ENDING/SEPARATION DATE
PREVIOUS EMPLOYER NAME AND ADDRESS IF EMPLOYED LESS THAN
FIVE YEARS
NO
STARTING DATE
GROSS
SOURCE
YES
MILITARY: IS DUTY STATION TRANSFER EXPECTED DURING NEXT YEAR?
WHERE
ENDING/SEPARATION DATE
PREVIOUS EMPLOYER NAME AND ADDRESS IF EMPLOYED LESS THAN
FIVE YEARS
ENDING DATE
REFERENCE
RELATIONSHIP
NAME AND ADDRESS OF NEAREST RELATIVE NOT LIVING WITH YOU
NO
STARTING DATE
ENDING DATE
REFERENCE
RELATIONSHIP
NAME AND ADDRESS OF NEAREST RELATIVE NOT LIVING WITH YOU
HOME PHONE
CUNA MUTUAL GROUP, 1980, 82, 84, 86, 89, 2000, 03, 04, 07, 11 ALL RIGHTS RESERVED PAGE
HOME PHONE
1
AXX12B-e
CREDITOR NAME OTHER THAN THIS CREDIT UNION
(Attach additional sheet(s) if necessary)
WHAT YOU OWE
INTEREST
RATE
LIST ANY NAMES UNDER WHICH YOUR CREDIT REFERENCES AND CREDIT HISTORY CAN BE CHECKED:
WHAT YOU OWN
TOTALS
LIST LOCATION OF PROPERTY OR FINANCIAL INSTITUTION
OTHER INFORMATION ABOUT YOU
MONTHLY
PAYMENT
PRESENT BALANCE
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
PLEDGED AS COLLATERAL
FOR ANOTHER LOAN
$
YES
NO
$
YES
NO
$
YES
NO
$
YES
NO
$
YES
NO
$
YES
NO
$
YES
NO
$
YES
NO
IF YOU ANSWER "YES" TO ANY QUESTION OTHER THAN #1, EXPLAIN ON AN ATTACHED SHEET
1.
ARE YOU A U.S. CITIZEN OR PERMANENT RESIDENT ALIEN?
2.
DO YOU CURRENTLY HAVE ANY OUTSTANDING JUDGMENTS OR HAVE YOU EVER FILED FOR BANKRUPTCY, HAD A DEBT ADJUSTMENT PLAN
CONFIRMED UNDER CHAPTER 13, HAD PROPERTY FORECLOSED UPON OR REPOSSESSED IN THE LAST 7 YEARS, OR BEEN A PARTY IN A LAWSUIT?
3.
IS YOUR INCOME LIKELY TO DECLINE IN THE NEXT TWO YEARS?
4.
ARE YOU A CO-MAKER, CO-SIGNER OR GUARANTOR ON ANY LOAN NOT LISTED ABOVE?
FOR WHOM (Name of Others Obligated on Loan):
TO WHOM (Name of Creditor):
OTHER
$
$
MARKET VALUE
OWED BY
APPLICANT
OWNED BY
APPLICANT OTHER
APPLICANT
OTHER
OHIO RESIDENTS ONLY: The Ohio laws
against discrimination require that all creditors
make credit equally available to all creditworthy customers, and that credit
reporting agencies maintain separate credit histories on each individual
upon request. The Ohio Civil Rights Commission administers compliance
with this law.
unless the Credit Union is furnished a copy of the agreement, statement or
decree, or has actual knowledge of its terms, before the credit is granted
or the account is opened. (2) Please sign if you are not applying for this
account or loan with your spouse. The credit being applied for, if granted,
will be incurred in the interest of the marriage or family of the
undersigned.
WISCONSIN RESIDENTS ONLY: (1) No provision of any marital property
agreement, unilateral statement under Section 766.59, or court decree
under Section 766.70 will adversely affect the rights of the Credit Union
SIGNATURE FOR WISCONSIN RESIDENTS ONLY
STATE LAW NOTICES
X
DATE
SIGNATURES
1. You promise that everything you have stated in this application is
correct to the best of your knowledge and that the above information is a
complete listing of what you owe. If there are any important changes you
will notify us in writing immediately. You authorize the Credit Union to
obtain credit reports in connection with this application for credit and for
any update, increase, renewal, extension or collection of the credit
received. You understand that the Credit Union will rely on the information
in this application and your credit report to make its decision. If you
request, the Credit Union will tell you the name and address of any credit
bureau from which it received a credit report on you. It is a federal crime
to willfully and deliberately provide incomplete or incorrect information on
loan applications made to federal credit unions or state chartered credit
unions insured by NCUA.
X
2. If you are applying for a credit card, you understand that the use of
your card will constitute acknowledgment of receipt and agreement to the
terms of the credit card agreement and disclosures. You grant us a
security interest in all individual and joint share and/or deposit accounts
you have with us now and in the future to secure your credit card
account. When you are in default, you authorize us to apply the balance in
these accounts to any amounts due. Shares and deposits in an Individual
Retirement Account, and any other account that would lose special tax
treatment under state or federal law if given as security, are not subject to
the security interest you have given in your shares and deposits.
X
(SEAL)
APPLICANT'S SIGNATURE
DATE
(SEAL)
DATE
OTHER SIGNATURE
FOR CREDIT UNION USE ONLY
DATE
APPROVED
APPROVED
LIMITS:
DENIED
(Adverse Action Notice Sent)
SIGNATURE
LINE OF CREDIT
OTHER
OTHER
$
$
$
$
DEBT RATIO/SCORE
BEFORE
AFTER
LOAN OFFICER COMMENTS:
SIGNATURES:
X
X
DATE
DATE
PAGE 2
AXX12B-e
VISA PLATINUM
F1
APPLICATION AND SOLICITATION DISCLOSURE
Interest Rates and Interest Charges
Annual Percentage Rate (APR) for
Purchases
APR for Balance Transfers
APR for Cash Advances
How to Avoid Paying Interest on Purchases
For Credit Card Tips from the Consumer
Financial Protection Bureau
Fees
Transaction Fees
- Foreign Transaction Fee
Penalty Fees
- Late Payment Fee
- Returned Payment Fee
F2
to F3
9.99%
18.00% when you open your account,
based on your creditworthiness.
F4
to 18.00%
F5
when you open your account, based on your
9.99%
creditworthiness.
F6
to 18.00%
F7
when you open your account, based on your
9.99%
creditworthiness.
Your due date is at least 25 days after the close of each billing cycle.
We will not charge you any interest on purchases if you pay your entire
balance by the due date each month.
To learn more about factors to consider when applying for or
using a credit card, visit the website of the Consumer Financial
Protection Bureau at http://www.consumerfinance.gov/learnmore.
F8
1.00%
of each transaction in U.S. dollars
Up to F9
$20.00
Up to F10
$25.00
How We Will Calculate Your Balance. We use a method called “average daily balance (excluding new purchases).”
Effective Date.
The information about the costs of the card described in this application is accurate as of F11
October 1, 2012.
This information may have changed after that date. To find out what may have changed, contact the Credit Union.
OTHER DISCLOSURES
Late Payment Fee
Returned Payment Fee
Statement Copy Fee
Document Copy Fee
Rush Fee
Emergency Card Replacement Fee
Card Replacement Fee
©CUNA Mutual Group 2009, 10, 12 All Rights Reserved
F12
or the amount of the required minimum payment, whichever
$20.00
is less, if you are five (5) or more days late in making a payment.
F13
or the amount of the required minimum payment, whichever
$25.00
is less.
F14
$5.00
F15
$5.00
F16
$35.00
F17
$35.00
F18
$5.00
DVTCO1 (MXC402 CCM002)-e
MEMBER'S DISCLOSURE NOTICE
FOR CREDIT LIFE AND/OR CREDIT DISABILITY INSURANCE
MEMBER'S CHOICE Credit Disability and Credit Life Insurance is underwritten by CMFG Life Insurance Company. Credit
Disability Insurance pays your monthly loan payment up to the policy maximum should you become totally disabled. Credit
Life Insurance reduces or pays off your loan balance if you die. A lump sum payment is paid to the credit union reflecting
your outstanding loan balance upon the receipt of proof of your death, up to the policy limits.
See the Application and Certificate of Insurance for Terms and Costs of Coverage
Be sure to read the Credit Insurance Application and Certificate which will explain the exact terms, conditions and
exclusions of the policy, the coverage amount and cost of the insurance. Credit Insurance premiums are usually added to
your loan. A refund of any unearned premium is paid if coverage ends, e.g., if you prepay the loan or cancel your
coverage.
Eligibility Requirements
- You must be under the maximum age for insurance stated on your Credit Insurance Application and Certificate to be
eligible for Credit Insurance.
- You must be working for wages or profit for 25 hours a week or more.
- If you are a homemaker, retiree or a student you are eligible for Credit Life Insurance if you are performing the usual
duties of a homemaker, retiree or student and you are not receiving disability benefits from another source.
- If you apply for insurance more than 30 days after your initial loan date, you will need to answer some health
questions to determine your insurability.
Exclusions
- The Credit Life Insurance excludes coverage for claims due to suicide within six months after the effective date of
coverage.
- The Credit Disability Insurance excludes coverage for claims due to a normal pregnancy or due to pre-existing
conditions six months after the original effective date of coverage resulting anytime during the six months preceding
the effective date of insurance.
Effective Date of Insurance Coverage
Your Credit Insurance coverage becomes effective on the same date that you complete the Credit Insurance Application
and sign your name acknowledging you are eligible for the insurance.
How to File a Claim
Claims may be filed electronically via Claims Online at www.cunamutual.com or by completing a Disability Claim Notice
available at your credit union and mailing or faxing it to:
CMFG Life Insurance Company
Attn: Credit Insurance Claims Department
P.O. Box 1621
Madison, WI 53791-8927
Fax: 1-608-218-1998
Received by:
Signature of Borrower #1
Date
Signature of Borrower #2
Date
CREDIT UNION COPY
IVTI13-e
MEMBER'S DISCLOSURE NOTICE
FOR CREDIT LIFE AND/OR CREDIT DISABILITY INSURANCE
MEMBER'S CHOICE Credit Disability and Credit Life Insurance is underwritten by CMFG Life Insurance Company. Credit
Disability Insurance pays your monthly loan payment up to the policy maximum should you become totally disabled. Credit
Life Insurance reduces or pays off your loan balance if you die. A lump sum payment is paid to the credit union reflecting
your outstanding loan balance upon the receipt of proof of your death, up to the policy limits.
See the Application and Certificate of Insurance for Terms and Costs of Coverage
Be sure to read the Credit Insurance Application and Certificate which will explain the exact terms, conditions and
exclusions of the policy, the coverage amount and cost of the insurance. Credit Insurance premiums are usually added to
your loan. A refund of any unearned premium is paid if coverage ends, e.g., if you prepay the loan or cancel your
coverage.
Eligibility Requirements
- You must be under the maximum age for insurance stated on your Credit Insurance Application and Certificate to be
eligible for Credit Insurance.
- You must be working for wages or profit for 25 hours a week or more.
- If you are a homemaker, retiree or a student you are eligible for Credit Life Insurance if you are performing the usual
duties of a homemaker, retiree or student and you are not receiving disability benefits from another source.
- If you apply for insurance more than 30 days after your initial loan date, you will need to answer some health
questions to determine your insurability.
Exclusions
- The Credit Life Insurance excludes coverage for claims due to suicide within six months after the effective date of
coverage.
- The Credit Disability Insurance excludes coverage for claims due to a normal pregnancy or due to pre-existing
conditions six months after the original effective date of coverage resulting anytime during the six months preceding
the effective date of insurance.
Effective Date of Insurance Coverage
Your Credit Insurance coverage becomes effective on the same date that you complete the Credit Insurance Application
and sign your name acknowledging you are eligible for the insurance.
How to File a Claim
Claims may be filed electronically via Claims Online at www.cunamutual.com or by completing a Disability Claim Notice
available at your credit union and mailing or faxing it to:
CMFG Life Insurance Company
Attn: Credit Insurance Claims Department
P.O. Box 1621
Madison, WI 53791-8927
Fax: 1-608-218-1998
Received by:
Signature of Borrower #1
Date
Signature of Borrower #2
Date
MEMBER COPY
IVTI13-e