APPLICANT'S STATEMENT Social Security # ________________________________

CREDITOR ADDRESS MO. PAYMENT AMT. OWING Home ______________________________________ $_________ $_________ Auto ______________________________________ $_________ $_________ Others 1_____________________________________ $_________ $_________ 2_____________________________________ $_________ $_________ 3_____________________________________ $_________ $_________ 4_____________________________________ $_________ $_________ 5_____________________________________ $_________ $_________

Employed by____________________  Address______________________________ Years Employed____ Position____________________ Bus. Phone______________ Clock/Payroll No._____________ Salary $_______ per _______ Date Of Birth ___________ Number Of Dependents (Exclude yourself)___ Home Phone________________

AUTO(S) OWNED MAKE MODEL YEAR _______________________ _______________________ _______ _______________________ _______________________ _______

Own Residence-$__________(Market Value) Rent Residence-$________(Monthly Rental)

REFERENCES _________________ _________________ _________________ _________________

Other Pertinent Information _________________________________________________________________ _________________________________________________________________

Other Income: (alimony, child support or seperate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation) _________________________________________________________________ _________________________________________________________________

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