Consumer Credit Application

* indicates a required field

IMPORTANT: Read these Directions before completing this Application.

Check Appropriate Box I am applying for a loan in my own name and I am relying on my own income or assets and not the income or assets of another person as the basis for repayment of the loan requested. Please complete only Section A.
I am applying for an individual loan, but I am 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 loan requested. Please complete all Sections to the extent possible, providing information in B about the person on whose alimony, support, or maintenance payments or income or assets you are relying.
We intend to apply for joint credit (enter your initials or name to indicate your intent). Please complete Sections A and B.

*Applicant
Co-Applicant

IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW LOAN: To help the government fight the funding of terrorism and money laundering activities, the USA Patriot Act requires all financial institutions to obtain, verify, and record information that identifies each person who opens a new account. What this means to you: If you do not have an existing financial relationship with this Bank, when you apply for credit, we will ask you for your name, physical address, date of birth, taxpayer identification number and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents. We will let you know if additional information is required.

REQUEST

*Loan Amount
*Payment Date
*Payment Amount
*Payment Frequency
*Funds from this credit are to be used for
*Secured/Unsecured
If to be Secured, DESCRIPTION of Asset offered as collateral
NAME of OWNER of Asset offered as collateral
*Branch Locations
*e-mail address

Everything that I have stated in this application is correct to the best of my knowledge. I understand that you will retain this application whether or not it is approved. You are authorized to check my credit and employment history and to answer questions about your credit experience with me.

*By entering my name here, I am providing my intent and certification of this application as if I were providing my signature
*Date
Other Signature (When Applicable)
Date
I would like to access this account through online banking

THANK YOU FOR APPLYING FOR A LOAN FROM THE CITIZENS STATE BANK.

WE STRIVE TO PROVIDE PROMPT AND PROFESSIONAL SERVICE. IF YOU HAVE QUESTIONS OR THE SERVICE YOU RECEIVE DOES NOT MEET YOUR EXPECTATIONS, PLEASE CONTACT US:

The Citizens State Bank
P.O. Box 110, 201 S. Christian
Moundridge, KS 67107
620-345-6317

* indicates a required field

*Last Name
*First Name
*Middle Initial
*Date of Birth
*Social Security Number
*Primary Phone Number
*Drivers License Number
*State of Issuance
*Date of Issuance
*Date of Expiration
*Country Citizenship
Ages of Dependents
*Present Street Address
*City, State ZIP	,
*Yrs at this Address
Present Mailing Address (if different than Street)
Mailing Address: City
Mailing Address: State
Mailing Address: ZIP
If you lease your residence, what is the monthly rent amount?
*MARITAL STATUS (Do not complete if this is an application for unsecured credit.)	Married Separated Unmarried (including single, divorced, or widowed)
*Present Employer
*Employer City, Employer State	,
*Gross Monthly Income
*Net Monthly Income
*Years at Job
*Work Phone
*Are you an active member of the Military or a dependent of an active member?	Yes No
*Are you a convicted felon?	Yes No
Previous Street Address (only if less than 2 years at current address)
City, State ZIP	,
Yrs at this Address
Previous Employer (only if less than 2 years at current employer)
Previous Employer City, Previous Employer State	,
Years at Previous Job
Phone
*Nearest Relative not living with you
*Address
*Phone #
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. If you do want this income considered as a repayment source, specify the amount of alimony, child support, and/or separate maintenance receiving and frequency.
*Are there any unsatisfied judgments against you?	Yes No
*Have you been declared bankrupt in the last 10 Years?	Yes No
*Is any income listed in this Section likely to be reduced in the next two years?	Yes No
*Are you a co-maker, endorser, or guarantor on any loan or contract?	Yes No
If "yes", for whom?
To whom?
Other Obligations - (e.g., contingent liablities, liability to pay alimony, child support, separate maintenance.)

Last Name
First Name
Middle Initial
Date of Birth
Social Security Number
Primary Phone Number
e-mail address
Drivers License Number
State of Issuance
Date of Issuance
Date of Expiration
Country Citizenship
Relation to Applicant
Ages of Dependents
Present Street Address
City, State ZIP	,
Yrs at this Address
Present Mailing Address (if different than Street)
Mailing Address: City
Mailing Address: State
Mailing Address: ZIP
If you lease your residence, what is the monthly rent amount?
MARITAL STATUS (Do not complete if this is an application for unsecured credit.)	Married Separated Unmarried (including single, divorced, or widowed)
Present Employer
Employer City
Employer State
Gross Monthly Income
Net Monthly Income
Years at Job
Occupation
Position or Title
Work Phone
Are you an active member of the Military?	Yes No
Are you a convicted felon?	Yes No
Previous Street Address (only if less than 2 years at current address)
City
State
ZIP
Yrs at this Address
Prior Employer (only if less than 2 years at current employer)
Previous Employer City
Previous Employer State
Years at Previous Job
Phone
Nearest Relative not living with you
Address
Phone #
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. If you do want this income considered as a repayment source, specify the amount of alimony, child support, and/or separate maintenance receiving and frequency.
Are there any unsatisfied judgments against you?	Yes No
Have you been declared bankrupt in the last 10 Years?	Yes No
Is any income listed in this Section likely to be reduced in the next two years?	Yes No
Are you a co-maker, endorser, or guarantor on any loan or contract?	Yes No
If "yes", for whom?
To whom?
Other Obligations - (e.g., contingent liablities, liability to pay alimony, child support, separate maintenance.)

Consumer Credit Application

REQUEST

SECTION A - APPLICANT INFORMATION

SECTION B - JOINT APPLICANT, USER, OR OTHER PARTY INFORMATION

THANK YOU FOR APPLYING FOR A LOAN FROM THE CITIZENS STATE BANK.