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Mortgage Application

Village Bank Short Form Residential Loan Application
Please print this form, fill it out and fax to 763-784-2105

General Information
Will you be applying for Individual or Joint Credit: emptycheckbox Joint emptycheckbox Individual
If applying for joint credit, please sign below to verify that you intend to apply for joint credit
Applicant: Co-Applicant:
Marital Status: Complete marital status if this loan is for:
a. Joint or secured credit, or
b. You reside in or rely on property located in a Community Property State. (AZ, CA, ID, LA, NM, NV, TX, WA, WI)
emptycheckbox Unmarried
emptycheckbox Married
emptycheckbox Separated
emptycheckbox This loan is not for joint or secured credit and I do not live in the states listed above.
Type of Loan Requested: Loan Amount Requested:
Loan Term Requested: Interest Rate Requested:
Primary Applicant
Last Name: Account Number:
First Name: Middle Name:
Social Security Number (TIN): Date of Birth:
Number of Dependents: Ages of Dependents:
Home Phone Number: Work Phone Number:
Other Phone Number: Email Address:
Drivers License #: Drivers License State:
Home Address
Address 1:
Address 2:
City: State, Zip:
Time at Current Residence: Residence Type: emptycheckbox Rent emptycheckbox Own emptycheckbox Other:
Monthly Payment:
Previous Address
Address 1:
Address 2:
City: State, Zip:
Time at Previous Residence: Residence Type: emptycheckbox Rent emptycheckbox Own emptycheckbox Other:
Present Employer
Name: Phone Number:
Employment Status: emptycheckbox Full Time emptycheckbox Part Time emptycheckbox Temp emptycheckbox Retired emptycheckbox Other (please specify):
Job Start Date: Job Title:
Gross Salary: per emptycheckbox Year emptycheckbox Month emptycheckbox Hour
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.
Other Income: per emptycheckbox Year emptycheckbox Month emptycheckbox Hour
Other Income Source:
Previous Employer
Name: Phone Number:
Employment Status: emptycheckbox Full Time emptycheckbox Part Time emptycheckbox Temp emptycheckbox Retired emptycheckbox Other (please specify):
Job Start Date: Job Title:
Job End Date:
Gross Salary: per emptycheckbox Year emptycheckbox Month emptycheckbox Hour

Co-Applicant

Last Name: Account Number:
First Name: Middle Name:
Social Security Number (TIN): Date of Birth:
Number of Dependents: Ages of Dependents:
Home Phone Number: Work Phone Number:
Other Phone Number: Email Address:
Drivers License #: Drivers License State:
Home Address
Address 1:
Address 2:
City: State, Zip:
Time at Current Residence: Residence Type: emptycheckbox Rent emptycheckbox Own emptycheckbox Other:
Monthly Payment:
Previous Address
Address 1:
Address 2:
City: State, Zip:
Time at Previous Residence: Residence Type: emptycheckbox Rent emptycheckbox Own emptycheckbox Other:
Present Employer
Name: Phone Number:
Employment Status: emptycheckbox Full Time emptycheckbox Part Time emptycheckbox Temp emptycheckbox Retired emptycheckbox Other (please specify):
Job Start Date: Job Title:
Gross Salary: per emptycheckbox Year emptycheckbox Month emptycheckbox Hour
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.
Other Income: per emptycheckbox Year emptycheckbox Month emptycheckbox Hour
Other Income Source:
Previous Employer
Name: Phone Number:
Employment Status: emptycheckbox Full Time emptycheckbox Part Time emptycheckbox Temp emptycheckbox Retired emptycheckbox Other (please specify):
Job Start Date: Job Title:
Job End Date:
Gross Salary: per emptycheckbox Year emptycheckbox Month emptycheckbox Hour
References
Nearest Relative Not Living With You
Last Name: First Name:
Relationship: Phone Number:
Address 1:
Address 2:
City: State, Zip:
Credit and Asset Information
Monthly Obligations
Installment Payments: Revolving Payments:
Mortgage Payments/Rent: Other Obligations:
Assets
Liquid Assets (cash,savings,etc.): Stocks, Bonds, Mutual Funds, etc.:
Fixed Assets (Real Estate, personal property, etc.):
Miscellaneous Property Information
(If you have property picked out, this does not obligate you to buy)
Property Type (Single Family, Condo, Vacation Home, Multi-Family, Commercial, Vacant Land):
Property Address 1:
Property Address 2:
Property City: State, Zip:
Annual Property Taxes: Annual Hazard Insurance:
Annual Condo/PUD Fees:

Home Mortgage Disclosure Act (HMDA)

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 home mortgage disclosure laws. You are not
required to furnish this information, but are encouraged to do so. You may select one or more designations for “Race”. The law
provides that a lender may not discriminate on the basis of this information, or on whether you choose to furnish it. However, if
you choose not to furnish the information and you have made this application in person, under federal regulations the lender is
required to note ethnicity, race, and sex on the basis of visual observation or surname. If you do not wish to furnish the
information, please check below.

Primary Applicant

Joint Applicant (If Applicable)

emptycheckbox I do not wish to furnish this information emptycheckbox I do not wish to furnish this information

Ethnicity:
emptycheckbox Hispanic or Latino
emptycheckbox Not Hispanic or Latino

Race:
emptycheckbox American Indian, Alaskan Native
emptycheckbox Asian
emptycheckbox Black or African American
emptycheckbox Native Hawaiian or Other Pacific Islander
emptycheckbox White

Sex: emptycheckbox Male emptycheckbox Female

Ethnicity:
emptycheckbox Hispanic or Latino
emptycheckbox Not Hispanic or Latino

Race:
emptycheckbox American Indian, Alaskan Native
emptycheckbox Asian
emptycheckbox Black or African American
emptycheckbox Native Hawaiian or Other Pacific Islander
emptycheckbox White

Sex: emptycheckbox Male emptycheckbox Female

Additional Information
How would you prefer to be contacted?
emptycheckbox Home Phone
emptycheckbox Work Phone
emptycheckbox Other Phone
emptycheckbox Email Address
emptycheckbox Other:
Special Instructions/Comments:


Signatures
Please note: Income verification is required; other information may be required.

I certify that statements on this application are true and complete. I authorize any person, association, firm or corporation to furnish, on request of this financial institution, information concerning me or my affairs.(Sec. 1014, Title 18, U.S. Code makes it a Federal Crime to knowingly make a false statement on this application.)
Primary Signature: Date:
Joint Owner Signature: Date: