THE FIRST STATE BANK OF ROSEMOUNT
Loan Application/Personal Financial Statement
IMPORTANT: Read these Directions before completing this Application.
Check
Appropriate
Box
If you are applying for individual unsecured credit in your own name and are relying on your own income or
assets and not the income or assets of another person as the basis for repayment of the credit requested,
complete only Sections A, D, E, F (as applicable) and H. If the requested credit is to be secured, also
complete Section C and all of Section F.
If you are applying for unsecured joint credit with another person, initial below and complete all Sections
except G, providing information in B, F and H about the joint applicant. If the requested joint credit is to be
secured, then complete Section G.
We intend to apply for joint credit.
Applicant
Co-Applicant
If you are applying for individual credit, but are relying on income from alimony, child support, or separate
maintenance or on the income or assets of another person as the basis for repayment of the credit
requested, complete all Sections except B. Complete Section G only if the credit will be secured.
Amount
Requested
Payment Date Desired
Proceeds of Credit To be Used For
$
SECTION A – Applicant Information
SECTION B – Co-applicant Information
Full Name (Last, First, Middle)
Full Name (Last, First, Middle)
Home Address Number and Street
Yrs/Mos
City, State, Zip Code
Home Address Number and Street
County
E-Mail Address
Date of Birth
Home Phone No.
Driver’s License No.
No. Dependents
Yrs/Mos
City, State, Zip Code
Social Security Number
E-Mail Address
Cell Phone No.
Date of Birth
Ages of Dependents
County
Social Security Number
Home Phone No.
Driver’s License No.
No. Dependents
Cell Phone No.
Ages of Dependents
Previous Home Address
Business Name or Employer
Yrs/Mos
Self Employed (Additional information required)
Co-Applicant’s Employer
Business Address Number and Street
Yrs/Mos
City, State, Zip Code
Business Address Number and Street
Business Phone
Position
Self Employed (Additional information required)
City, State, Zip Code
Present Monthly
Salary and/or Commissions
$
Business Phone
Position
Previous Employer
Yrs/Mos
Yrs/Mos
Present Monthly
Salary and/or Commissions
$
Co-Applicant’s Previous Employer
Yrs/Mos
The following is: † Information for Applicant
The following is: † Information for Co-applicant
You need NOT disclose alimony, child support or separate maintenance income unless you want us to consider it for purposes of this application.
Monthly Interest & Dividend Income
$
Rental Income
Other Monthly Income
$
$
Please describe the sources of Other Income.
SECTION C - Marital Status (Do not complete if this is an application for individual unsecured credit.)
Applicant
Married
Separated
Co-Applicant
Married
Separated
Unmarried (including single, divorced, and widowed)
Unmarried (including single, divorced, and widowed)
SECTION D - Credit References
Name
Address (Street or P.O. Box, City, State, Zip
Code)
Phone Number
(Complete Page 2, as Applicable)
FSB Rosemount 9/08
fb.us.3250768.06
1
Account # or Description
Date Paid/Closed
SECTION E – Asset and Debt Information
Rent Home
Own Home in the following name(s):
Monthly Rent or Payment
Purchase Price
Original Loan Amount
Balance Owing
Present Value
$
$
$
$
$
Date Purchased
Name and address of Mortgage Holder or Landlord
Name of My Bank
Checking Account No.
Name of nearest relative not living with you
Savings Account No.
Address
Phone No.
ASSETS OWNED (detail on separate sheet if necessary)
Description
OUTSTANDING DEBTS (detail on separate sheet if necessary)
Amount
Amount Owed
1.
Cash
10.
Bank
Loans-Unsecured
2.
Stocks or Bonds
11.
Bank
Loans-Secured
3.
Real Estate
12.
Real Estate
Loans
4.
Automobiles
13.
Auto Loans or
Lease Payments
5.
Cash Value of Life Insurance (Face Value)
14.
Life Ins. Loans
6.
Notes Receivable
15.
Credit Cards
7.
IRA, Keogh or Retirement Funds
16.
Other Liabilities
8.
Other Assets
9.
Networth of Business
TOTAL ASSETS
Relationship
$
TOTAL LIABILITIES
$
TOTAL ASSETS minus TOTAL LIABILITIES = NET WORTH
$
Mo. Payments
$
SECTION F – Additional Information
Applicant
Yes
Co-Applicant
Yes
No
No
Explanation (Use an additional sheet if necessary.)
Yes
No
Yes
No
Have you ever been declared bankrupt?
Yes
No
Yes
No
Yes
No
Yes
No
Have you had property foreclosed upon or given title or
deed in lieu thereof in the last 7 years?
Are you party to a lawsuit?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Are you obligated on any loan resulting in judgment,
foreclosure or title transfer?
Are you delinquent/in default on any Federal debt,
financial obligation, bond, or loan guarantee?
Are you obligated to pay alimony, child support, or
separate maintenance?
Is any part of the down payment borrowed?
Yes
No
Yes
No
Are you a co-maker or an endorser on a loan?
Yes
No
Yes
No
Have you ever been denied credit by us?
Yes
No
Yes
No
Are you a U.S. citizen?
Yes
No
Yes
No
If no, are you a resident alien?
Yes
No
Yes
No
If no, are you a non-resident alien?
Are there any outstanding judgments against you?
Other Income you want us to consider that is not stated in Section A or B
Alimony, child support or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.
PARTIES INCOME TYPES: A=Alimony/Child Support B = Bonuses C = Commissions I = Interest & Dividends O = Overtime R = Retirement X = Other
App
CoA
Joint
Type
Description
Amount
Frequency
Significant Monthly Expenses
Expense types:
PARTIES
App
CoA
Joint
D = Dues-Homeowner Application H = Hazard Insurance P = Private Mortgage Insurance R = Rent T = Taxes (Property) U = Utilities
A = Alimony/Child Support C = Child/Dependent Care E = Estimated Living Expenses F = Federal & State Taxes I = Insurance Payments
M = Medical O = Other
Type
Description
Amount
Frequency
SECTION G – Secured Credit (Briefly describe the property to be given as security.)
List names/addresses of all co-owners of the property to be given as collateral:
Name
Address
SECTION H – Signature(s)
By signing below, I confirm that: 1) Everything that I have stated in this application is correct to the best of my knowledge; 2) you will retain this application whether or not it is approved; 3)
you are authorized to check my credit and employment history and to answer questions about your credit experience with me.
Applicant’s Signature
FSB Rosemount 9/08
fb.us.3250768.06
Date
Other Signature
(Where Applicable)
2
Date
Rev. 01/2011
FACTS
Why?
What?
WHAT DOES THE FIRST STATE BANK OF ROSEMOUNT DO
WITH YOUR PERSONAL INFORMATION?
Financial companies choose how they share your personal information. Federal law gives
consumers the right to limit some but not all sharing. Federal law also requires us to tell you how
we collect, share, and protect your personal information. Please read this notice carefully to
understand what we do.
The types of personal information we collect and share depend on the product or service you
have with us. This information can include:



Social Security number and Income
Credit history and transaction history
Payment history and checking account information
When you are no longer our customer, we continue to share your information as described in this
notice.
How?
All financial companies need to share customers’ personal information to run their everyday
business. In the section below, we list the reasons financial companies can share their
customers’ personal information; the reasons The First State of Rosemount chooses to share;
and whether you can limit this sharing.
Does The First State Bank
of Rosemount share?
Can you limit this sharing?
For our everyday business purposes—
such as to process your transactions, maintain
your account(s), respond to court orders and legal
investigations, or report to credit bureaus
Yes
No
For our marketing purposes—
to offer our products and services to you
No
We don't share
For joint marketing with other financial companies
No
We don't share
For our affiliates’ everyday business purposes—
information about your transactions and experiences
No
We don't share
For our affiliates’ everyday business purposes—
information about your creditworthiness
No
We don't share
For nonaffiliates to market to you
No
We don't share
Reasons we can share your personal information
Questions?
Call 651-423-1121 or go to www.fsbrosemount.com
Page 2
What we do
How does The First State Bank of
Rosemount protect my personal
information?
How does The First State Bank of
Rosemount collect my personal
information?
To protect your personal information from unauthorized access
and use, we use security measures that comply with federal
law. These measures include computer safeguards and
secured files and buildings.
We collect your personal information, for example, when you



Apply for a loan or open an account
Deposit money or make a wire transfer
Provide account information
We also collect your personal information from other companies.
Why can’t I limit all sharing?
Federal law gives you the right to limit only



sharing for affiliates’ everyday business purposes—information
about your creditworthiness
affiliates from using your information to market to you
sharing for nonaffiliates to market to you
State laws and individual companies may give you additional rights to
limit sharing.
Definitions
Affiliates
Companies related by common ownership or control. They can be
financial and nonfinancial companies.

Nonaffiliates
Companies not related by common ownership or control. They can be
financial and nonfinancial companies.

Joint marketing
The First State Bank of Rosemount does not share with nonaffiliates
so they can market to you
A formal agreement between nonaffiliated financial companies that
together market financial products or services to you.

Other important information
The First State Bank of Rosemount has no affiliates.
The First State Bank of Rosemount doesn't jointly market