Home Equity Line of Credit Application

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1 Applicant s Name 322 East Main Avenue Bismarck, ND (701) Lender Please tell us about yourself and co-applicant, if applicable Co-Applicant s Name Home Equity Line of Credit Application Home Address Number and Street Yrs/Mos Home Address Number and Street Yrs/Mos City, State, Zip Code County City, State, Zip Code County Social Security Number Home Phone. Date of Birth Social Security Number Home Phone. Date of Birth Driver s License.. Dependents Age of Dependents Driver s License.. Dependents Age of Dependents Applicant s Previous Home Address Business Name or Employer Self Employed (Additional Information required) About Your Job(s) Yrs/Mos Co-Applicant s Employer Self Employed (Additional Information required) Business Address Number and Street Yrs/Mos Business Address Number and Street Yrs/Mos City, State, Zip Code Business Phone City, State, Zip Code Business Phone Position Personal Monthly Employment Income Position Personal Monthly Employment Income Previous Employer Yrs/Mos Co-Applicant s Previous Employer Yrs/Mos About Your Other Income You need not disclose alimony, child support or separate maintenance income unless you want us to consider it for purposes of this application. Annual Interest & Dividend Income Monthly Child Support or separate maintenance Other Monthly Household Income Please describe the sources of other household income. Marital Status Do not complete if this is an Application for individual unsecured credit. Applicant Co-Applicant Married Separated Unmarried (including single, divorced, widowed) Married Separated Unmarried (including single, divorced, widowed) Rent Home Own Home in the following name(s): Monthly Rent or Payment Purchase Price Name and address of Mortgage Holder or Landlord Name of My Bank judgment filed against you or declared bankruptcy? YES Date: Name of nearest relative not living with you: Cash in Banks Stocks or Bonds Automobiles ASSETS (Attach details ) NO About Your Existing Loans and Accounts Original Loan Amount Balance Owing Present Value Checking Account. Have you ever had a Savings Account. Monthly child support or separate maintenance payment Address Phone. Relationship OBLIGATIONS Date Purchased Assets Value Description Amount Owed Monthly Payment Unsecured Bank Loans Secured Bank Loans Auto Loans Real Estate Life Insurance (Face Value) Retirement Funds, IRA s Other Assets Other Assets Total Real Estate Obligations Life Insurance Loans Credit Card Debt Other Obligations TOTAL ASSETS TOTAL OBLIGATIONS NET WORTH I/We represent that this application is complete and accurate and fully reflects my/our financial condition on the date shown below. I/We authorize Lender to obtain a credit report and any other information it deems necessary about my/our credit worthiness. I/We agree to notify Lender immediately, in writing, of any adverse change in my/our financial condition. I/we understand that Lender will retain this Application whether or not it is approved. Lender may share information about you with other organizations that are its affiliates unless you direct Lender not to do so. If you do not want Lender to share such information with its affiliates, please initial here 7 Applicant s Signature Date 7 Co-Applicant s Signature Date

2 Information Disclosure Authorization To Whom it May Concern: I/We hereby authorize you to release to its successors and/or assigns, for verification purposes, information concerning: [ X ] Employment history, dates, title, income, hours worked, etc [ X ] Checking, savings, and investment accounts (including copies of statements, etc.). [ X ] Mortgage/Consumer/Business loan rating, (opening date, high credit, payment amount, loan balance, and payment record). [ X ] Personal and business records from accountants, attorneys, etc that may have information required for the processing of a loan. [ X ] Any information deemed necessary in connection with a credit report for a mortgage/consumer/business loan transaction. The information if for the confidential use of the lender in determining my/our creditworthiness for a mortgage/consumer/ business purpose loan. A PHOTOGRAPHIC COPY of the under sign s authorization MAY BE DEEMED TO BE THE EQUIVALENT OF THE ORIGINAL and MAY BE USED AS A DUPLICATE ORIGINAL. The original signed form is maintained in the BNC NATIONAL BANK, 322 EAST MAIN, BISMARCK, ND OFFICE. Your prompt reply will help my/our loan transaction. EQUAL CREDIT OPPORTUNITY ACT NOTICE The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided that the applicant has the capacity to enter into a binding contract), because all or part of the applicant s income derives from any public assistance program, or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with this law concerning the Department of Housing and Urban Development is the Federal Trade Commission, Equal Credit Opportunity, Washington, D.C is regulated by the Comptroller of the Currency, 2345 Grand Ave., Suite 700, Kansas City, MO Signature Signature Social Security Number Social Security Number Date I/we authorize to share my/our account and application information as they deem appropriate to any affiliate of for marketing purposes. (BORROWER(S) INITIALS REQUIRED FOR ACCEPTANCE) 2

3 Important Information 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 you 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. Date By: 3

4 Important Information Account Number: Disclosure Statement Borrowers of are not required to obtain insurance from a particular insurance company. Any insurance required as a condition of the extension of credit by may, without affecting approval of the application for an extension of credit, be purchased from an insurance company of the Borrower s choice. Date By:

5 Rev. 10/10 FACTS Why? What? How? WHAT DOES BNC NATIONAL BANK DO WITH YOUR PERSONAL INFORMATION? Financial companies choose how they share your personal information. Federal law gives consumers the right to limit some but not all sharing. Federal law also requires us to tell you how we collect, share, and protect your personal information. Please read this notice carefully to understand what we do. The types of personal information we collect and share depend on the product or service you have with us. This information can include: n Social Security number and account balances n Account transactions and checking account information n Payment history and mortgage rates and payments When you are no longer our customer, we continue to share your information as described in this notice. All financial companies need to share customer personal information to run their everyday business. In the section below, we list the reasons financial companies can share their customer personal information; the reasons chooses to share; and whether you can limit this sharing. Reasons we can share your personal information For our everyday business purposes such as to process your transactions, maintain your account(s), respond to court orders and legal investigations, or report to credit bureaus For our marketing purposes to offer our products and services to you For joint marketing with other financial companies For our affiliates everyday business purposes information about your transactions and experiences For our affiliates everyday business purposes information about your creditworthiness For nonaffiliates to market to you Does BNC National Bank share? Yes Yes Can you limit this sharing? Questions? Go to

6 Page 2 Who we are Who is providing this notice? What we do How does protect my personal information? To protect your personal information from unauthorized access and use, we use security measures that comply with federal law. These measures include computer safeguards and secured files and buildings. How does collect my personal information? We collect your personal information, for example, when you n Open an account or apply for a loan n Make deposits or withdrawals from your account n Use your ATM or Debit card or seek financial or tax advice Why can t I limit all sharing? Definitions Affiliates Federal law gives you the right to limit only n sharing for affiliates everyday business purposes information about your creditworthiness n affiliates from using your information to market to you n sharing for nonaffiliates to market to you State laws and individual companies may give you additional rights to limit sharing. Companies related by common ownership or control. They can be financial and nonfinancial companies. n does not share with our affiliates. n Affiliates Joint marketing Companies not related by common ownership or control. They can be financial and nonfinancial companies. n naffiliates we share with can include mortgage companies and service providers that provide printing and mailing services in connection with our marketing to you. A formal agreement between nonaffiliated financial companies that together market financial products or services to you. n doesn t jointly market.

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