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Citizens National Bank
Couple looking at a new home

Uniform Residential Loan Application


*Indicates a Required Field

Applicants should complete this form as "Borrower" or "Other/Co-Borrower," as applicable. Co-Borrower information must also be provided (and the appropriate box checked) when:


I. Type of Mortgage and Terms of Loan

Mortgage applied for: *
Amortization Type

II. Property Information and Purpose of Loan

Purpose of Loan: *
Complete the following if this is a construction or construction-permanent loan.

Complete the following if this is a refinance loan.

Estate will be held in: *

III. Borrower Information

Primary Borrower Information

Own or Rent at Current Address? *Primary Borrower

If residing at current address for less than two years, please complete the following:

Own or Rent at Former Address? Primary Borrower

Other/Co-Borrower Information

Own or Rent at Current Address? Other/Co-Borrower

If residing at current address for less than two years, please complete the following:

Own or Rent at this address?Other/Co-Borrower

IV. Employment Information

Primary Borrower Employment Information

Primary Borrower If employed in current position for less than two years or if currently employed in more than one position, please complete the following:

Other/Co-Borrower Employment Information

Other/Co-Borrower If employed in current position for less than two years or if currently employed in more than one position, please complete the following:

V. Monthly Income and Combined Housing Expense Information

Combined Monthly Housing Expense

VI. Assets and Liabilities

This statement and any applicable supporting schedules may be completed jointly by both married and unmarried Co-Borrowers if their assets and liabilities are sufficiently joined so that the Statement can be meaningly and fairly presented on a combined basis; otherwise, separate Statements and Schedules are required. If the Co-Borrower section was completed about a non-applicant spouse or other person, this Statement and supporting schedules must be completed about that spouse or other person also.

Application Completed: *

Assets

Attach Financial Statement
Asset 1
Asset 2
Asset 3
Asset 4
Asset 5

List Checking and Savings Accounts Below.

Checking or Savings Account 1
Checking or Savings Account 2
Checking or Savings Account 3
Checking or Savings Account 4

Stocks and Bonds

Life Insurance

Automobiles Owned

Automobile 1
Automobile 2
Automobile 3
Automobile 4
Automobile 5

Other Assets: Itemize

Other Asset 1
Other Asset 2
Other Asset 3
Other Asset 4
Other Asset 5

Liabilities

Liabilities and Pledged Assets

List the creditor's name, address, and account number for all outstanding debts, including automobile loans, revolving charge accounts, real estate loans, alimony, child support, stock pledges, etc.

Liability 1
Liability 2
Liability 3
Liability 4
Liability 5
Liability 6
Alimony/Child Support/Separate Maintenance Payments

Notice: Alimony, child support, or separate maintenance income need not be revealed if the Borrower or Co-Borrower does not choose to have it considered for repaying this loan.

Job-Related Expenses (child care, union dues, etc.)

Schedule of Real Estate Owned

Property 1
Property 2
Property 3
Property 4
Property 5

Property Totals

List any additional names under which credit has previously been received and indicate appropriate creditor name(s) and account number(s):

Additional Name 1
Additional Name 2
Additional Name 3

VII: Details of Transaction

VIII: Declarations

Borrower Declarations

Are there any outstanding judgments against you? *
Have you declared bankruptcy in the past seven years? *Primary Borrower
Have you had property foreclosed upon or given title or deed in lieu thereof in the last seven years? *Primary Borrower
Are you party to a lawsuit? *Primary Borrower
Have you directly or indirectly been obligated on any loan which resulted in foreclosure, transfer of title in lieu of foreclosure, or judgment? *Primary Borrower
Are you presently delinquent or in default on any Federal debt or any other loan, mortgage, financial obligation, bond, or loan guarantee? *Primary Borrower
Are you obligated to pay alimony, child support, or separate maintenance? *Primary Borrower
Is any part of the down payment borrowed? *Primary Borrower
Are you a co-maker or endorser on a note? *Primary Borrower
Do you intend to occupy the the property as your primary residence? *Primary Borrower
If yes, have you had an ownership interest in a property in the last three years? Primary Borrower
Are you a US Citizen? *Primary Borrower
Are you a permanent resident alien? *Primary Borrower

Other/Co-Borrower Declarations

Are there any outstanding judgments against you?
Have you declared bankruptcy in the past seven years? Co-Borrower
Have you had property foreclosed upon or given title or deed in lieu thereof in the last seven years? Co-Borrower
Are you party to a lawsuit? Co-Borrower
Have you directly or indirectly been obligated on any loan which resulted in foreclosure, transfer of title in lieu of foreclosure, or judgment? Co-Borrower
Are you presently delinquent or in default on any Federal debt or any other loan, mortgage, financial obligation, bond, or loan guarantee? Co-Borrower
Are you obligated to pay alimony, child support, or separate maintenance? Co-Borrower
Is any part of the down payment borrowed? Co-Borrower
Are you a co-maker or endorser on a note? Co-Borrower
Do you intend to occupy the the property as your primary residence? Co-Borrower
If yes, have you had an ownership interest in a property in the last three years? Co-Borrower
Are you a US Citizen? Co-Borrower
Are you a permanent resident alien? Co-Borrower

IX. Information For Government Monitoring Purposes

The following information is requested by the Federal Government for certain types of loans related to a dwelling in order to monitor the lender's compliance with equal credit opportunity, fair housing and ho me mortgage disclosure laws. You are not required to furnish this in formation, but are encouraged to do so.

The law provides that a lender may not discriminate either on the basis of this information, or on whether you choose to furnish it. If you furnish the information, please provide both ethnicity and race. For race, you may check more than one designation. If you do not furnish ethnicity, race, or sex, under Federal regulations, this lender is required to note the information on the basis of visual observation and surname if you have made this application in person.

If you do not wish to furnish the information, please check the box below. (Lender must review the above material to assure that the disclosures satisfy all requirements to which the lender is subject under applicable state law for the particular type of loan applied for.)

Borrower Optional Info

Ethnicity Primary Borrower
Race Primary Borrower

Other/Co-Borrower Optional Info

Ethnicity Co-Borrower
Race Co-Borrower

X. Acknowledgement and Agreement

By submitting this form, Borrower and Other/Co-Borrower (if applicable) acknowledge and agree to the following:

I. If this is an application for joint credit, Borrower and Other/Co-Borrower each agree that we intend to apply for joint credit.

II. Each of the undersigned specifically represents to Lender and to Lender's actual or potential agents, brokers, processors, attorneys, insurers, servicers, successors and assigns and agrees and acknowledges that:

(1) the information provided in this application is true and correct as of the date set forth opposite my signature and that any intentional or negligent misrepresentation of this information contained in this application may result in civil liability, including monetary damages, to any person who may suffer any loss due to reliance upon any misrepresentation that I have made on this application, and/or in criminal penalties including, but not limited to, fine or imprisonment or both under the provisions of Title 18, United States Code, Sec. 1001, et seq.;

(2) the loan requested pursuant to this application (the "Loan") will be secured by a mortgage or deed of trust on the property described in this application;

(3) the property will not be used for any illegal or prohibited purpose or use;

(4) all statements made in this application are made for the purpose of obtaining a residential mortgage loan;

(5) the property will be occupied as indicated in this application;

(6) the Lender, its servicers, successors or assigns may retain the original and/or an electronic record of this application, whether or not the Loan is approved;

(7) the Lender and its agents, brokers, insurers, servicers, successors, and assigns may continuously rely on the information contained in the application, and I am obligated to amend and/or supplement the information provided in this application if any of the material facts that I have represented herein should change prior to closing of the Loan;

(8) in the event that my payments on the Loan become delinquent, the Lender, its servicers, successors or assigns may, in addition to any other rights and remedies that it may have relating to such delinquency, report my name and account information to one or more consumer reporting agencies;

(9) ownership of the Loan and/or administration of the Loan account may be transferred with such notice as may be required by law;

(10) neither Lender nor its agents, brokers, insurers, servicers, successors or assigns has made any representation or warranty, express or implied, to me regarding the property or the condition or value of the property; and

(11) my transmission of this application as an "electronic record" containing my "electronic signature," as those terms are defined in applicable federal and/or state laws (excluding audio and video recordings), or my facsimile transmission of this application containing a facsimile of my signature, shall be as effective, enforceable and valid as if a paper version of this application were delivered containing my original written signature.

III. Each of the undersigned hereby acknowledges that any owner of the Loan, its servicers, successors and assigns, may verify or reverify any information contained in this application or obtain any information or data relating to the Loan, for any legitimate business purpose through any source, including a source named in this application or a consumer reporting agency.

IV. I/We fully understand that it is a Federal crime punishable by fine or imprisonment, or both, to knowingly make any false statements concerning any of the above facts as applicable under the provisions of Title 18, United States Code, Section 1001, et seq.

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