HELOC Application PremierBank

Federal Deposit Insurance Corporation FDIC-Insured - Backed by the full faith and credit of the U.S. Government

Phone: 920-563-6616

Routing No.: 075902175

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Home Equity Line of Credit Application

PremierBank is based in Fort Atkinson, Wisconsin and has physical locations in Jefferson, Rock, and Walworth Counties focusing on lending to people in the south central Wisconsin area.

Loan Information

($) Amount Requested(Required)

Which loan officer are you currently working with?(Required)

APPLICANT(S) Check one of the following boxes. You may apply for separate credit in your name only, joint credit in your and the name of your spouse, or joint credit in your name and the name(s) of other joint applicant(s). Note: Separate credit and joint credit may also be marital purpose debt under Wisconsin Law.

(Required)

Separate Credit. Complete your personal information. Completethe co-applicants information about your spouse only if you are married and a Wisconsin resident.

Joint Credit with spouse as joint applicant. Complete your personal information and the co-applicant information.

Joint Credit with (name below) as joint applicant who is not your spouse. Each joint applicant must complete a separate application as if applying for separate credit. Please also note this in the Additional Comments Section so we can put the two applications together.

Joint Applicant Name(Required)

Loan Purpose

Personal Information

First Name(Required)

Middle Initial

Last Name(Required)

Social Security Number(Required)

Birthdate(Required)

Select Marital Status

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email

Housing Information

Length of Residence(Required)

Months / Years(Required)

Select Housing Status(Required)

($) Monthly Payment(Required)

Mortgage Holder

($) Estimated Property Holder

($) Mortgage Balance

Employment Information

Employer

Telephone Number

Supervisor

Street Address

City

State

Zip Code

Position/Department

Length Of Employment

($) Income

Select Increment

Financial Information

Do you have a Checking Account?

Yes

No

Checking Account Number

Financial Institution

Do you have a Savings Account?

Yes

No

Savings Account Number

Financial Institution

Other Debt Information

Please list all

Type of Debt (Car, Loan, Credit Cards)

Balance

($) Monthly Payment

Declarations

Are you obliged to make alimony, support or maintenance payments?

Yes

No

Are you a co-signer, endorser or guarantor on any loan or contract?

Yes

No

If so, for whom?

To whom?

Are there any unsatisfied judgements against you?

Yes

No

Have you ever declared bankruptcy?

Yes

No

If yes, where? (City/State)

What year?

Additional Comments

Please Note: Alimony, child support, or maintenance income need not be revealed if you do not wish it to be considered as a basis for repaying this obligation. Notice to married applicant: No provision of a marital property agreement, a unilateral statement under Wis. Stat. sec 766.59 or a court decree under Wis. Stat. sec 766.70 adversely affects the interests of the bank unless prior to the time the credit is extended, the bank is furnished with a copy of the agreement statement or decree, or has actual knowledge of the adverse provision when the obligation to the bank is incurred. Submission of this form authorizes PremierBank to verify information provided herein, including but not limited to employment and credit history.

Do you need to fill out co-applicant information?(Required)

Yes

No

Co-Applicant Personal Information

What is your relation to applicant?

Name(Required)

First Middle Last

Social Security Number(Required)

Birth Date(Required)

Select Marital Status

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email

Housing Information

Length of Residence(Required)

Months / Years(Required)

Select Housing Status(Required)

($) Monthly Payment(Required)

Mortgage Holder

($) Estimated Property Value

($) Mortgage Balance

Employment Information

Employer

Telephone Number

Supersvisor

Street Address

City

State

Zip Code

Position/Department

Length of Employment

($) Income

Select Increment

Financial Information

Do you have a Checking Account?

Yes

No

Checking Account Number

Financial Institution

Do you have a Savings Account?

Yes

No

Savings Account Number

Financial Institution

Please list all

Type of Debt (Car, Loan, Credit Cards)

Balance

($) Monthly Payment

Declarations

Are you obliged to make alimony, support or maintenance payments?

Yes

No

Are you a co-signer, endorser or guarantor on any loan or contract?

Yes

No

If so, for whom?

To whom?

Are there any unsatisfied judgements against you?

Yes

No

Have you ever declared bankruptcy?

Yes

No

If yes, where? (City, State)

What year?

Additional Comments

Please Note: Alimony, child support, or maintenance income need not be revealed if you do not wish it to be considered as a basis for repaying this obligation. Notice to married applicant: No provision of a marital property agreement, a unilateral statement under Wis. Stat. sec 766.59 or a court decree under Wis. Stat. sec 766.70 adversely affects the interests of the bank unless prior to the time the credit is extended, the bank is furnished with a copy of the agreement statement or decree, or has actual knowledge of the adverse provision when the obligation to the bank is incurred. Submission of this form authorizes PremierBank to verify information provided herein, including but not limited to employment and credit history.

Important Information About Procedures for Opening a New Account

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. What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents. You will be required to come into one of our locations to complete the loan process. (Sign loan papers, verify information, etc.)

Disclosure Information(Required)

I acknowledge that I have read the Early Disclosure of Home Equity Loans and the CFPB What You Should Know About Home Equity Lines of Credit

Privacy Policy Information

You must choose one of the following options.(Required)

I agree to accept PremierBank's Notice of Privacy Policy electronically.

I would like to receive PremierBank's Notice of Privacy Policy by mail.

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