CO-MAKER'S STATEMENT

Co-Maker Name___________________ Address_____________________________

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________________ Relation to Applicant (If any) ___________________

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

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

REFERENCES
_________________ _________________ _________________ _________________
I certify that the above statements are true and complete.

Date_____________    Signature Of Co-Maker__________________________

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