USA PATRIOT ACT INFORMATION DISCLOSURE
Important Information about Application Procedures
To help the government fight the funding of terrorism and money laundering activities,
Federal Law requires all financial institutions to obtain, verify and record information
that identifies every customer.
What this means to you: When you apply for a loan, we will ask for your name, address,
date of birth and other information that will allow us to identify you. We may also ask to
see your driver’s license or other identifying documents.
Authorization to Release Financial Information
Date:
_____________________
Borrower:
_____________________
_____________________
_____________________
Accountant:
______________________
______________________
______________________
Lender:
CBC National Bank
1887 South 14th Street
Fernandina Beach, FL 32034
In consideration of an extension of credit made to me by the Lender, I authorize any
accountant or tax preparer, including but not limited to the Accountant named above, to
provide CBC National Bank with tax returns, financial statements, or other financial
information related to my personal finances or legal entities in which I have an ownership
interest. I understand that this agreement will remain in force so long as I have any open
credit facility with the Lender.
_______________________________
Borrower
_____________
Date
Borrower’s Preference to Legal Counsel and Insurance Agent You have the right to select the legal counsel who shall represent you in all matters relating to the closing of a loan extended to you pursuant to this application and to select the homeowners’ insurance agent who is to furnish the insurance required in connection with the mortgage which shall secure the loan so extended. I/ We designate the following as legal counsel to represent me/us: Attorney name/address: ____________________________________________________ I/We designate the following as insurance agent to provide insurance coverage: Insurance Agent’s name/address:______________________________________________ _______________________________________ ___________________________________________ Borrower Date Borrower Date _______________________________________ Borrower Date COMMERCIAL APPLICATION NOTICE
TYPE OF ACCOUNT REQUESTED
Check one to indicate the type of account you are requesting. Note: married applicants may apply for
separate accounts.
 Joint Account – We intend to apply for joint credit.
Applicant initials:__________
Joint Applicant initials: __________ Joint Applicant
initials: __________


Individual Account – Relying solely on my income and assets.
Individual Account – Relying on my income and assets as well as income or assets of another.
Application Date: ________________________________
Purpose of Loan: _________________________________
REAL ESTATE COLLATERAL
You have the right to a copy of the appraisal report used in conjunction with your application for credit if
your loan is to be secured by a 1-4 family dwelling. If you wish a copy, please write to us at the mailing
address we have provided. We must hear from you no later than 90 days after we notify you about the
action taken on your credit application or you withdraw your application. In your letter, give us the
following information: date of application, name of the applicant, property address and your current
mailing address.
CUSTOMER IDENTIFICATION
To help the government fight the funding of terrorism and money laundering activities, Federal law
requires all financial institutions to obtain, verify, and record information that identifies each person who
opens an account, including loans.
What this means to you: When you open an account, we will ask for your name, address, date of birth,
and other information that will allow us to identify you. We will ask to see your driver’s license or other
identifying information.
CREDIT DENIAL NOTICE
If your gross revenues were $1,000,000.00 or less in your previous fiscal year, or you are requesting trade
credit or similar type of business credit and if your application for business credit is denied, you have the
right to a written statement of the specific reasons for the denial. To obtain the statement please contact the
bank at the address provided within 60 days from the date you are notified of our decision. We will send
you a written statement of the specific reasons for the denial within 30 days of receiving your request for
the statement.
EQUAL CREDIT OPPORTUNITY NOTICE
The federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants
on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the
capacity to enter into a binding contract), because all or part of the applicant’s income is from any public
assistance program, or because the applicant has in good faith exercised any right under the Consumer
Credit Protection Act. The federal agency that administers compliance with this law concerning this
creditor is:
Office of the Comptroller of the Currency
1301 McKinney Street, Suite 3450
Houston, Texas 77010
800-613-6743
I/we acknowledge below that I/we received a copy of this notice on this _____ day of _______, 20___
Applicant_______________________________Joint Applicant______________________________
Joint Applicant___________________________
NOTICE OF RIGHT TO RECEIVE COPY OF APPRAISAL
“You” means the Applicant(s) and “I/We” means the Lender
You have the right to a copy of the appraisal report used in connection with your
application for credit. If you wish a copy, please write to us at the mailing address
we have provided. We must hear from you no later than 90 days after we notify you
about the action taken on your credit application or you withdraw your application.
In your letter, please give us the following information: Loan or application
number, if known, date of application, name(s) of loan applicant(s), property
address, and your current mailing address.
ACKNOWLEDGEMENT
By signing below, you acknowledge that you have read and understood the Notice of
your right to receive a copy of the appraisal.
_______________________
Borrower
_______________________
Borrower
_______________________
Borrower
______________
Date
______________
Date
______________
Date
Certification of Personal Financial Statement
I/We hereby certify that the enclosed financial statement of _____________________
Bank is intended for use by CBC National Bank, 1887 South 14th Street, Fernandina
Beach, FL 32034 for the purpose of obtaining credit for the Applicant(s) or for the
purpose of the Applicant(s) guaranteeing credit for others. I/We further certify that all
information contained therein is true and correct in every detail and represents the
financial condition of the Applicant(s) on the date given below. CBC National Bank is
authorized to make all inquiries deemed necessary to verify the accuracy of the
information contained therein and to determine the creditworthiness of the undersigned.
Applicant(s) will promptly notify CBC National Bank of any subsequent changes which
would affect the accuracy of the enclosed statement. Applicant(s) are aware that any
knowing or willing false statements regarding property values listed therein for purposes
of influencing the actions of CBC National Bank can be a violation of federal law 18
U.S.C. sec. 1014 and may result in a fine or imprisonment or both.
In addition, each individual signing below authorizes the CBC National Bank to check
their individual credit account and employment history and have a credit reporting
agency prepare a credit report on each.
The undersigned declares that he/she has read and understands the statements above.
Applicant Signature____________________________________Date______________
Applicant Signature____________________________________Date______________
Personal Financial Statement as of _________
Applicant
NAME
Co-Applicant
NAME
SOCIAL SECURITY #
BIRTHDATE
SOCIAL SECURITY #
ADDRESS
ADDRESS
EMAIL ADDRESS
EMAIL ADDRESS
BIRTHDATE
HOME PHONE
OFFICE PHONE
HOME PHONE
OFFICE PHONE
CELL PHONE
FAX
CELL PHONE
FAX
OCCUPATION
LENGTH OF
EMPLOYMENT
OCCUPATION
LENGTH OF
EMPLOYMENT
EMPLOYER
EMPLOYER
EMPLOYER’S ADDRESS
EMPLOYER’S ADDRESS
ACCOUNTANT NAME & PHONE
ACCOUNTANT NAME & PHONE
ATTORNEY NAME & PHONE
ATTORNEY NAME & PHONE
INSURANCE AGENT NAME & PHONE
INSURANCE AGENT NAME & PHONE
Annual Income
Annual Expenditures
SALARIES
FEDERAL & STATE INCOME TAXES
BONUSES/COMMISSIONS
REAL ESTATE TAXES
DIVIDEND/INTEREST INCOME
INSURANCE
RENTAL INCOME
RENTAL PAYMENTS/MAINTENANCE
CAPITAL GAINS
MORTGAGE/LOAN PAYMENTS
PARTNERSHIP INCOME
ALIMONY/CHILD SUPPORT
OTHER INCOME (SPECIFY) *
OTHER EXPENSES (SPECIFY)
TOTAL INCOME
TOTAL EXPENDITURES
* Alimony, child support, or separate maintenance income need not be revealed unless you wish to have it considered as a basis
for repaying this obligation.
Assets
Liabilities
CASH IN
CBC NATIONAL BANK
REVOLVING CREDIT CARDS PAYABLE
CASH IN OTHER BANKS
(NAME)
MARGIN ACCOUNTS PAYABLE
(SCHEDULE B)
OTHER ACCOUNTS PAYABLE
(SCHEDULE C)
NOTES & LEASES PAYABLE
(SCHEDULE C)
CASH VALUE OF LIFE INSURANCE
(SCHEDULE A)
MORTGAGES PAYABLE
(SCHEDULE D)
MARKETABLE SECURITIES
(SCHEDULE B)
REAL ESTATE TAXES PAYABLE
PERSONAL RESIDENCE
(SCHEDULE D)
BUSINESS DEBT
(SCHEDULE E)
OTHER REAL ESTATE OWNED
(SCHEDULE D)
INCOME TAXES PAYABLE
CLOSELY HELD BUSINESS VENTURES
(SCHEDULE E)
OTHER LIABILITIES
(SPECIFY)
IRA’S/VESTED RETIREMENT
ACCOUNTS
PERSONAL PROPERTY
(SCHEDULE G)
OTHER ASSETS
(SPECIFY)
TOTAL ASSETS
TOTAL LIABILITIES
NET WORTH (Total Assets minus Total Liabilities)
TOTAL CONTINGENT LIABILITIES (SCHEDULE F)
SCHEDULE A – CASH VALUE OF LIFE INSURANCE
COMPANY
OWNER
BENEFICIARY
FACE
AMOUNT
LOAN
AMOUNT
CASH
SURRENDER
VALUE
SCHEDULE B – MARKETABLE SECURITIES
STOCKS # OF SHARES
BONDS FACE VALUE
OWNER
DESCRIPTION
Page 2 of 5
PLEDGED
Y/N
COST
MARKET
VALUE
SCHEDULE C – ACCOUNTS, NOTES & LEASES PAYABLE
LENDER
COLLATERAL
TERMS
MATURITY
ORIGINAL
BALANCE
MONTHLY
PAYMENT
UNPAID BALANCE
SCHEDULE D – REAL ESTATE OWNED/MORTGAGES
PROPERTY ADDRESS
%
OWNED
BOUGHT
DATE
PRICE
MONTHLY
RENTAL
INCOME
MORTGAGE
BALANCE
MONTHLY
PAYMENT
MARKET
VALUE
SCHEDULE E – CLOSELY HELD BUSINESS VENTURES*
TYPE OF BUSINESS/INVESTMENT
%
OWNED
TOTAL
ASSETS
TOTAL
LIABILITIES
LOANS
PAYABLE
MONTHLY
PAYMENT
MARKET
VALUE
*Please attach any financial statements/tax returns relevant to the partnership(s), LLC’s, S-CORP’s, etc. and include
schedule K-1’s.
Page 3 of 5
SCHEDULE F – CONTINGENT LIABILITIES
YES*
AMOUNT
NO
Are you an endorser, co-maker, or guarantor on any debt for any individual or
organization?
Are you a defendant in any lawsuits or legal actions?
Do you have any outstanding letters of credit or surety bonds?
Are you a signer on any other leases or contracts?
Are any of your state, federal or local tax obligations past due?
Have you, or any organization in which you were part owner, declared bankruptcy
within the past 10 years?
Any other assets or liabilities not listed on schedules herein?
Have you drawn a will? Please list executor and
date:____________________________________
CONTINTENT LIABILITIES – LOANS PAYABLE
LENDER
COLLATERAL
TERMS
MATURITY
ORIGINAL
BALANCE
MONTHLY
PAYMENT
UNPAID BALANCE
* If you answer yes to any of these questions, please give details sufficient to analyze your obligation.
SCHEDULE G – PERSONAL PROPERTY OWNED
DESCRIPTION
%
OWNED
ORIGINAL COST
PURCHASE DATE
FAIR
MARKET
VALUE
BALANCE
OWED
LENDER
The information herein and on all accompanying statements is provided for the expressed purpose of obtaining credit for the Applicant(s) or for others with the
guarantee of the undersigned. The undersigned acknowledge that that all representations made in these statements will be relied upon by the Creditor in its
decision to grant or continue extension(s) of credit. The undersigned represent that all information contained in these statements are true, correct and complete as
of the date given below. The undersigned further attests that any material adverse change, to include name, address, employment and monetary asset or liability,
will be reported to the Creditor within a reasonable period of time. In the absence of such notification of change, Creditor will consider the attached statements as
continuing and substantially correct. If it is discovered that the information contained is not accurate in any material respect, and that notification has not been
made, then the Creditor may proclaim the indebtedness of the undersigned, or the indebtedness guaranteed by the undersigned, immediately due and payable.
Creditor is authorized to make all necessary inquiries, to include employment history and credit reporting agency credit reports, to verify the accuracy of the
information contained herein and to further determine the credit worthiness of the undersigned. Creditor is further authorized to answer any questions about
Creditor’s experience with the undersigned. Also, by signing below, Applicant(s) acknowledge that any knowing or willful false statements herein made for the
purpose of influencing the actions of the Creditor can be a violation of federal law 18 U.S.C. section 1014 and may result in a fine, imprisonment or both.
____________________________
APPLICANT SIGNATURE
___________________
DATE
____________________________
CO-APPLICANT SIGNATURE
___________________
DATE
Page 4 of 5
RENT ROLL
Property Address:
Date: ___________________
TENANT NAME
TOTAL:
UNIT #
ANNUAL
RENT
SQ FT
-
$
-
______________________________________
Signature
Date
Page 5 of 5
C.A.M.
EXPENSE
RECOVERY
$
-
LEASE TERMS
DEBT SCHEDULE
Entity Name:
Loan
Number
Date:
Bank
Loan
Origination
Date
Original
Amount
Borrowed
Interest
Rate
Monthly
Payment
Current
Loan
Balance
Maturity
Date
Collateral Description
Maturity
Date
Collateral Description
CONTINGENT LIABILITIES (Loans you personally guaranteed)
Loan
Number
Bank
BY:_________________________________
Signature
Loan
Origination
Date
Original
Amount
Borrowed
Interest
Rate
Monthly
Payment
Current
Loan
Balance
Regulation B Notice to Apply for Joint Credit Notice: We intend to apply for Joint Credit. Acknowledgement: By signing below, we acknowledge the intention to apply for joint credit on today’s date. X_____________________________ Borrower Date X_____________________________ Borrower Date X_____________________________ Borrower Date