Loan Application

*Indicates a Required Field

Credit Request Info

Type of Credit Requested *

Secured Unsecured Individual Credit Joint Credit

Reason for Loan * Amount Requested *

Payment Frequency *

For How Long *

Desired Payment Date *

Collateral *

Primary Applicant

Primary Applicant First Name *

Primary Applicant MI *

Primary Applicant Last Name *

Primary Applicant Date of Birth *

Primary Applicant Last 4 Digits of SSN *

Primary Applicant Number of Dependents *

Primary Applicant Ages of Dependents

Primary Applicant Phone *

Primary Applicant Driver's License Number *

Primary Applicant Address *

Primary Applicant City *

Primary Applicant State *

Primary Applicant Zip Code *

Primary Applicant County *

Primary Applicant How Long at Current Address? *

Own or Rent? *Primary Applicant

Own

Rent

Primary Applicant Previous Address if Less Than 2 Years at current address

Primary Applicant Previous Address City

Primary Applicant Previous Address State

Primary Applicant Previous Address Zip Code

Primary Applicant Previous County

Primary Applicant How Long at Previous Address?

Own or Rent? Primary Applicant Previous Address

Own

Rent

Primary Applicant Employment Info

Primary Applicant Employer Name * Primary Applicant Employer Address *

Primary Applicant Employer City *

Primary Applicant Employer State *

Primary Applicant Employer Zip Code *

Primary Applicant Position/Title *

Primary Applicant Business Phone *

Primary Applicant How Long at Current Employer? *

Primary Applicant Gross Monthly Salary *

Primary Applicant Net Monthly Salary *

Primary Applicant Previous Employer Name * Primary Applicant Previous Employer Address *

Primary Applicant Previous Employer City *

Primary Applicant Previous Employer State *

Primary Applicant Previous Employer Zip Code *

Primary Applicant How Long at Previous Employer? *

Primary Applicant - Other Income

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: Primary Applicant Court Order Written Agreement Oral Understanding

Primary Applicant Other Income Description

Primary Applicant Amount Per Month

Is any income listed above likely to be reduced before the credit requested is paid off? Primary Applicant

Yes

Primary Applicant If yes, Explain.

Primary Applicant Other Info

Have you ever received credit from us? *Primary Applicant

Yes

Primary Applicant Checking Account Number

Primary Applicant Savings Account Number

Primary Applicant Nearest Relative Info

Primary Applicant Name of nearest relative not living with you *

Primary Applicant's Relationship to Nearest Relative *

Primary Applicant Nearest Relative Phone *

Primary Applicant Relative Address *

Primary Applicant Nearest Relative City *

Primary Applicant Nearest Relative State *

Primary Applicant Nearest Relative Zip Code *

Joint/Other Applicant

Joint/Other Applicant First Name

Joint/Other Applicant MI

Joint/Other Applicant Last Name

Joint/Other Applicant Date of Birth

Joint/Other Applicant Last 4 Digits of SSN

Joint/Other Applicant Number of Dependents

Joint/Other Applicant Ages of Dependents

Joint/Other Applicant Phone

Joint/Other Applicant Driver's License Number

Joint/Other Applicant Address

Joint/Other Applicant City

Joint/Other Applicant State

Joint/Other Applicant Zip Code

Joint/Other Applicant County

Joint/Other Applicant How Long at Current Address?

Own or Rent? Joint/Other Applicant

Own

Rent

Joint/Other Applicant Previous Address if Less Than 2 Years at current address

Joint/Other Applicant Previous Address City

Joint/Other Applicant Previous Address State

Joint/Other Applicant Previous Address Zip Code

Joint/Other Applicant Previous County

Joint/Other Applicant How Long at Previous Address?

Own or Rent? Joint/Other Applicant Previous Address

Own

Rent

Joint/Other Applicant Employment Info

Joint/Other Applicant Employer Name Joint/Other Applicant Employer Address

Joint/Other Applicant Employer City

Joint/Other Applicant Employer State

Joint/Other Applicant Employer Zip Code

Joint/Other Applicant Position/Title

Joint/Other Applicant Business Phone

Joint/Other Applicant How Long at Current Employer?

Joint/Other Applicant Gross Monthly Salary

Joint/Other Applicant Net Monthly Salary

Joint/Other Applicant Previous Employer Name Joint/Other Applicant Previous Employer Address

Joint/Other Applicant Previous Employer City

Joint/Other Applicant Previous Employer State

Joint/Other Applicant Previous Employer Zip Code

Joint/Other Applicant How Long at Previous Employer?

Joint/Other Applicant - Other Income

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: Joint/Other Applicant Court Order Written Agreement Oral Understanding

Joint/Other Applicant Other Income Description

Joint/Other Applicant Amount Per Month

Is any income listed above likely to be reduced before the credit requested is paid off? Joint/Other Applicant

Yes

Joint/Other Applicant If yes, Explain.

Joint/Other Applicant Other Info

Have you ever received credit from us? Joint/Other Applicant

Yes

Joint/Other Applicant Checking Account Number

Joint/Other Applicant Savings Account Number

Joint/Other Applicant Nearest Relative Info

Joint/Other Applicant Name of nearest relative not living with you

Joint/Other Applicant's Relationship to Nearest Relative

Joint/Other Applicant Nearest Relative Phone

Joint/Other Applicant Relative Address

Joint/Other Applicant Nearest Relative City

Joint/Other Applicant Nearest Relative State

Joint/Other Applicant Nearest Relative Zip Code

Asset and Debt Information

Assets Owned

Total Assets *

Outstanding Debts

include charge accounts, installment contracts, credit cards, mortgage, etc.

Mortgage

Mortgage Debt Mortgage Holder or Landlord Mortgage Debt Name on Account Mortgage Debt Account Number

Mortgage Debt Amount of Loan

Mortgage Debt Present Loan Balance

Mortgage Debt Monthly Payments

Automobile

Auto 1 Debt Creditor Name Auto 1 Debt Name on Account Auto 1 Debt Account Number

Auto 1 Debt Amount of Loan

Auto 1 Debt Present Loan Balance

Auto 1 Debt Monthly Payments

Other Creditor or Additional Automobile 1

Other Debt 1 Creditor Name Other Debt 1 Name on Account

Other Debt 1 Account Number

Other Debt 1 Amount of Loan

Other Debt 1 Present Loan Balance

Other Debt 1 Monthly Payments

Other Creditor or Additional Automobile 2

Other Debt 2 Creditor Name Other Debt 2 Name on Account

Other Debt 2 Account Number

Other Debt 2 Amount of Loan

Other Debt 2 Present Loan Balance

Other Debt 2 Monthly Payments

Other Creditor or Additional Automobile 3

Other Debt 3 Creditor Name Other Debt 3 Name on Account

Other Debt 3 Account Number

Other Debt 3 Amount of Loan

Other Debt 3 Present Loan Balance

Other Debt 3 Monthly Payments

Other Creditor or Additional Automobile 4

Other Debt 4 Creditor Name Other Debt 4 Name on Account

Other Debt 4 Account Number

Other Debt 4 Amount of Loan

Other Debt 4 Present Loan Balance

Other Debt 4 Monthly Payments

Other Creditor or Additional Automobile 5

Other Debt 5 Creditor Name Other Debt 5 Name on Account

Other Debt 5 Account Number

Other Debt 5 Amount of Loan

Other Debt 5 Present Loan Balance

Other Debt 5 Monthly Payments

Other Creditor or Additional Automobile 6

Other Debt 6 Creditor Name Other Debt 6 Name on Account

Other Debt 6 Account Number

Other Debt 6 Amount of Loan

Other Debt 6 Present Loan Balance

Other Debt 6 Monthly Payments

Total Debts *

Total Amount of Loan(s) * Total Present Loan Balance * Total Monthly Payments *

Complete the following information about both the Primary Applicant and Joint or Other Applicant (if applicable)

Primary or Joint/Other Applicant, are you obligated to make Alimony, Support or Maintenance payments? *

Yes

If yes, please answer the following:

Payment Amount Per Month

Payment Recipient

Payment Recipient Address

Payment Recipient City

Payment Recipient State

Payment Recipient Zip Code

Primary or Joint/Other Applicant, are you a co-maker, endorser, or guarantor on any loan or contract? *

Yes

Loan Endorser If yes, for whom?

Loan Endorser If yes, to whom?

Primary or Joint Applicant, are there any unsatisfied judgments against you? *

Yes

Unsatisfied Judgments If yes, to whom?

Amount:

Primary or Joint Applicant, have you declared bankruptcy in the past 10 years? *

Yes

If yes, where?

Year

Secured Credit

Property Description

Name of First Co-Owner of the property

First Co-Owner Address

First Co-Owner City

First Co-Owner State

First Co-Owner Zip Code

Name of Second Co-Owner of the property

Second Co-Owner Address

Second Co-Owner City

Second Co-Owner State

Second Co-Owner Zip Code

If the security is real estate, give the full name of your spouse, if applicable.

Credit Disclosures

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.

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Loan Application

Credit Request Info

Primary Applicant

Primary Applicant Employment Info

Primary Applicant - Other Income

Primary Applicant Other Info

Primary Applicant Nearest Relative Info

Joint/Other Applicant

Joint/Other Applicant Employment Info

Joint/Other Applicant - Other Income

Joint/Other Applicant Other Info

Joint/Other Applicant Nearest Relative Info

Asset and Debt Information

Assets Owned

Checking Account(s)

Checking Account 1

Checking Account 2

Checking Account 3

Checking Account 4

Checking Account 5

Savings Accounts

Savings Account 1

Savings Account 2

Savings Account 3

Savings Account 4

Savings Account 5

Certificate(s) of Deposit

Certificate of Deposit 1

Certificate of Deposit 2

Certificate of Deposit 3

Certificate of Deposit 4

Certificate of Deposit 5

Real Estate

Real Estate 1

Real Estate 2

Real Estate 3

Real Estate 4

Real Estate 5

Marketable Securities

Marketable Security 1

Marketable Security 2

Marketable Security 3

Marketable Security 4

Marketable Security 5

Life Insurance

Life Insurance 1

Life Insurance 2

Life Insurance 3

Life Insurance 4

Life Insurance 5

Automobiles

Automobile 1

Automobile 2

Automobile 3

Automobile 4

Automobile 5

Other Assets

Other Asset 1

Other Asset 2

Other Asset 3

Other Asset 4

Other Asset 5

Outstanding Debts

Mortgage

Automobile

Other Creditor or Additional Automobile 1

Other Creditor or Additional Automobile 2

Other Creditor or Additional Automobile 3

Other Creditor or Additional Automobile 4

Other Creditor or Additional Automobile 5

Other Creditor or Additional Automobile 6

Total Debts *

Secured Credit

Credit Disclosures