Loan Application
Crossroads Financial FCU
1102 West Votaw Street, Portland, IN 47371
Phone:260-726-2142, Fax:260-726-6846

Applicant Information:
* Required Fields
*Loan Amount Requested:
$
*Type of Loan Requested:
 
I agree to the Terms/Conditions of the Disclosure
* Member Number: (if not a member put: NONE)
* SSN: (###-##-#### - no dashes)
* DOB: (MM/DD/YYYY - no slashes)
* First, Middle, Last Name:
* Email Address:
Marital Status:
* Home Phone Number: (###-###-#### - no dashes)
Cell Number:
(###-###-#### - no dashes)
Applicant Home Address:  
Time at Current Residence: Yrs: Mos:
Do you Rent or Own?:
If Rent/Other, enter landlord:
Current Address:
Apt/Suite #:
Current City:
Current State:
Current Zip: -
Current Housing Monthly Pymt: $
If living at Current Address < 3 years complete Previous Address info.
Previous Address:
Previous City:
Previous State:
Previous Zip: -
Time at Previous Residence: Yrs: Mos:
Applicant Employer:    
Name:  
Job Title/Occupation:  
Phone Number:   (ex: ###-###-#### - no dashes)
Time Employed:   Yrs: Mos:
Gross Salary:   $ Per
If working at Current Employer < 3 years complete Previous Employer info.
Previous Employer:    
Name:  
Job Title/Occupation:  
Phone Number:   (ex: ###-###-#### - no dashes)
Time Employed:   Yrs: Mos:
Other Income:    
Other Income Source:  
Other Income:   $ Per
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.

Will there be a Co-Applicant on this application? If Yes select the Co-Applicant Type?
If you have indicated that there will be a coapplicant on this loan: I/WE UNDERSTAND THAT BY COMPLETING THE CO-APPLICANT INFORMATION THAT THE CREDIT UNION MAY NOTIFY ME AND THE COAPPLICANT IN WRITING OR BY TELEPHONE TO VERIFY THEIR WISHES TO BE CO-APPLICANT AND THAT I/WE FULLY UNDERSTAND THIS APPLICATION IS FOR JOINT CREDIT.
Co-Applicant Info:  
* Required Fields
* Member Number:   (if not a member put: NONE)
* SSN:   (ex: ######### - no dashes)
* DOB:   (ex: MM/DD/YYYY - no slashes)
*First, Middle, Last Name:  
* Email Address:  
*Home Phone Number:   (ex: ###-###-#### - no dashes)
Cell Number:   (ex: ###-###-#### - no dashes)
CoApp Home Address:
 
Time at Current Residence:   Yrs: Mos:  
Do you Rent or Own?:  
If Rent/Other, enter landlord:  
Current Address:  
Apt/Suite #:  
Current City:  
Current State:  
Current Zip:   -
Housing Monthly Payment:   $
If CoApp living at Current Address < 3 years complete Previous Address info.
Previous Address:  
Previous City:  
Previous State:  
Previous Zip:   -
Time at Previous Residence:   Yrs: Mos:
CoApp Employer:
Name:  
Job Title/Occupation:  
Phone Number:   (ex: ###-###-#### - with dashes)
Time Employed:   Yrs: Mos:
Gross Salary:   $ Per
If CoApp working at Current Employer < 3 years complete Previous Employer info.
CoApp Previous Employer:
Name:
 
Job Title/Occupation:  
Phone Number:   (ex: ###-###-#### - with dashes)
Time Employed:   Yrs: Mos:
CoApp Other Income:
Other Income Source:  
Other Income:   $ Per
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.
Special Loan Instructions or Other Comments.

Income verification is required. Other information may be required. Loan Approval and Interest Rate is determined by your credit history.

I certify that statements on this application are true and complete. I authorize any person, association, firm or corporation to furnish, on request of this Credit Union, information concerning me or my affairs. (Sec. 1014, Title 13, U.S. Code makes it a Federal Crime to knowingly make a false statement on this application.) Income verification is required. Other information may be required. Loan Approval and Interest Rate is determined by your credit history. By clicking the submit button below, I hereby apply for credit with your credit union. Further, I agree to and accept the terms of the Disclosure.

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. This policy is in compliance with the USA PATRIOT Act's Customer Identification Policy (CIP). In opening the account, the person will be asked for the following information: name, date of birth, street address, and identification number. Documents that will be accepted for verification of identity include current/active government-issued identification bearing a photograph, such as a driver's license or passport, social security card, or worker ID. We will also verify identification by calling ChexSystems or running a credit report.