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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.
include charge accounts, installment contracts, credit cards, mortgage, etc.
If yes, please answer the following:
An insurance product or annuity may be offered to you. If you purchase an insurance product or an annuity:
(1) The insurance product or annuity is not a deposit or other obligation of, or guaranteed by, this institution or our affiliates;
(2) With exception of Federal Flood Insurance or Federal Crop Insurance, the insurance product or annuity is not insured by the FederaI Deposit Insurance Corporation or any other agency of the United States, this institution, or our affiliates; and
(3) In the case of an insurance product or annuity that involves an investment risk, there is investment risk associated with the insurance product, including the loss of value. If an insurance product or annuity is offered we cannot condition an extension of credit on either of the following:
(3a) Your purchase of an insurance product or annuity from us or any of our affiliates; or
(3b) Your agreement not to obtain, or a prohibition on you from obtaining, an insurance product or annuity from an unaffiliated entity.
By submitting this form, I certify that everything I have stated in this application is correct. Citizens National Bank may keep this application whether or not it is approved. I authorize Citizens National Bank to check my credit and employment history and to answer questions others may ask Citizens National Bank about my credit record. I understand that I must update credit information at the request of Citizens National Bank if my condition changes.