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CREDIT R • IMPORTANT APPLICANT INFORMA-MR: Federal law requires financial Institutions to obtain sufficient information to verity your identity.Ycu may be asked several qua ons and to pmvideione or more forms of identification to fulfill this requirement,in some instances we may use outside sources to Confirm the,information.The information you provide is protected by our pdvacy policy 4nd federal law. TYPE OF CRE T QUESTED '' ✓I �� ::I Secured Unsecured Date of Application f0 Citizens State Bank NYA KIndividual Credit-relying on my income or assets. ATTN:LOAN DEPT Amount$ dd wLon ndividual Credit-relying on my income or assets P.O.BOX 769 Payment Desired 3 1 d013 as wen as income or assets from other sources. NYA,MN 55366 Want to Repay ❑Monthly ❑ Joint Credit-Weintend to.apply-for joint credit. Purpose t (initials) LENDER'S NAME AND ADDRESS Acct.No. Class Pi*44111[11111111012111111 a' /' • LAST FPST M.1. /� -i 7' '� �J Name A 5 Birth Date ca-� Tel.No."(5�- �( -��'y Sec.Sec.No.-`7� Present Address "L Z-f nnina-uLn t) city � (stale_� Sip=.55 3�?w County How Long Previous Address 3 tI " ; c--11 City�?1,4 Ta�u,Fy�—yY�.1—a_Zip Jr,J�I X07 County_(n Ll.lY�Yq.r How Long Have you applied for credit with us before? ❑.No Yes-When? / �f.Lf f V"D' �G?�i�\t5'0VV 5No.Dep._S!Dep:Ages Name of Ne st Relative Not Living With You - u `` C �� Relation shi Address attfry1 V ill_ � h!11 f rnh ��Qr Tel.No. Employer(Company Name y&Address) f�� s How Long r `p Bus.Tel f��4�_r Poshion,'Tide + ,A T m 1 IN §V N61 Often Paid? Y aka Home Salary Per Month r C u* Previous Employer(Company Name&Address) n t jq of 06 hi-6!`(((rill. How Long 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. Alimony,child support,separate maintenance received under: ❑Court Order ❑Written Agreement Ll Oral Understanding Sources of Other Income Amount Per Month$ Complete only fF for joint credit,for individual credit relying on income or assets from other sources,or applicant is married and resides in a community property state. LAST FIRST M,I. Name _._......_Birth Date Tel.No. Soc.Sat..No. _ Present Address ___.- City State Zip County How Long Relationship To Applicant(If Arty) Have you applied for credit with us before? ❑No ❑Yes-When? No.Dep. Dep.Ages Name of Nearest Relative Not Living With You Relationship Address — Tel,No.( ) ...._.._.._..... Employer(Company Name&Address) How Long Bus.Tel. PositiortTitle How Often Paid? Take Home Salary Per Month$ 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. Alimony,child support,separate maintenance received under: ❑Court Order ❑Written Agreement ❑Oral Understanding Sources of Other Income Amount Per Month$ a Complete only it forjointAor secured credit,or applicant resides in a unity property state or is won property located Ssu h3 rate. Unmarried gie uwcrced a u rt w�:n}� PP ❑Bdanisd [IS epara rttna - Odw ©Maarrietl If Section B has been comppleted,this Section should be completed giving information about both the Applicant and Joint Applicant or Other Person.Please mark Applic xnt-related information with an"A.'If Saction B was not completed,only give information about the Applicant in this Section. ASSETS OWNED(Use separats sheet it nscessa . T DESCRIPTION OF ASSETS NAME IN WHICH THE ACCOUNT IS CARRIED a0� chec kng Account N mber(s). l j/ Q D 3+>ZfS C 4u oil V� t� $ _W (where)re) P u i at I Saving)Accou N bar( 'ni of 5 �A FF,Azie (where) S ik lnp Cr 3ei ,n t s Other Asts &Lr pV✓5-- L A4,n V[L (describe) TOTAL ASSETS OUTSTANDING DEBTS (include charge aocourds,installment contracts,credit cards,rent,mortgages and other obligations.Use separate sheet it necessary) C CREDITOR ACCOUNT NUMBER NAME.THE ACCT.IS UNDER ORIGINAL AMT. I PRESENT BAL. MO. PMTS.. • I n� ❑Rent Payment (OMIT RENT) (OMIT RENT; landlord or /v y( � Mortgage Holder ❑Mo triage $ �- $ $ Automobiles J,nka model, arl /ty t� _ _