Application Form ONLY APPLICATIONS SUBMITTED ON THIS FORM WILL BE PROCESSED BY THE OFFICER

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1 Application Form ONLY APPLICATIONS SUBMITTED ON THIS FORM WILL BE PROCESSED BY THE OFFICER Applicant s details Loan Member Amount of loan Repayment Terms X w/f/m Cheque /Cash Loan Approved/Refused Payment day Title First names Surname/known by any other name /maiden name Have you applied for a loan before Address Postcode Other names and/or addresses used within previous 3 years Postcode Contact telephone numbers: landline work mobile National Insurance Any other previous names /partners surname Purpose of loan: Loan Amount Breakdown of loan amount: Applicant Profile Information Gender Age Male Female Date of Birth: Ethnicity White British White Irish White other Mixed White and Black Caribbean Mixed White and Asian Mixed White and Other Asian or Asian British Indian Asian or Asian British Asian or Asian British Asian or Asian British other 1

2 Pakistani Bangladeshi background Chinese Romany/Gypsy/Traveller Other... 2

3 Employment Status Unemployed Employed Full-time Employed part-time Self employed Student Retired Incapacity Other. Employer Contact Details How long employed. Is the applicant in receipt of welfare/benefits? Yes If Yes, please give details. Would they describe yourself as having a disability or a long tem illness? Yes Does the applicant have a history of high interest borrowing? Yes Housing Information Owner occupier Privately rented Local Authority/Housing Association rented Name of landlord. Living with family/friends fixed abode Household Composition Lone parent Couple (no children) Couple with children Single person Banking Information Does the applicant have a bank account? Yes Will you be opening a bank account if successful with this application? Yes My Personal Data, the Credit Union I have been advised that Carlisle &District Credit Union are registered under the Data Protection Act 1998, Registration Number Z ,and intends to hold personal data supplied by me on Membership Applications, Loan Applications, Share Withdrawal and Transfers, either manually or on the Credit Union database. In accordance with the principles of the Data Protection Act 1998, we will use your personal details for the purposes of managing your accounts with the credit union. Declaration: I agree that information may be retained for the above purpose and to give me access to services provided by the Credit Union. I will inform you if I think any information you hold is inaccurate so that you may correct it. If I request you will provide a copy of the information you hold on me in line with the provisions of the Data Protection Act (I understand a fee may be payable). The confidential information you hold on me should only be disclosed outside the credit union : at my written request or with my written consent or to facilitate the recovery of unpaid debts (to an authorised debt collection agency) or to investigate or prevent fraud or if the law permits and a warrant is executed, or it is in the public interest. (Please delete as applicable) You may/may not contact me regarding services of the Credit Union which you believe may be of interest to me including newsletters I would prefer not to receive any information from you about other services Please tick Signed Date / /20 3

4 Name Income and Expenditure Form in household Adult ages Childrens ages Income: Weekly/Monthly (delete) Debts Amount Payment Wage : applicant Rent/ Mortgage Wage : partner Council Tax JSA Water Rates Income Support Gas Child Benefit Electric WTC & FTC Court Fines Others Maintenance Loans/prov/shpa/bh/wonga Pay day/money shop Credit card TOTAL : Store Cards Catalogues Expenditure: Weekly/Monthly (delete) HP payments/interest free Rent/ Mortgage overdraft Council Tax TOTAL (B) Water Rates Gas TOTAL INCOME : Electricity TOTAL EXPENDITURE(A+B) Contents Insurance Disposable Income Telephone landline Telephone mobile TV costs & license/sky Housekeeping - food cigarettes School meals/expenses Kids pocket money/child care fees/nursery Travel expenses/petrol Clothing Pets/insurance Car loan Car tax, repairs & insurance Pensions/Life Assurance Any Other/going out /gambling/bingo/take aways TOTAL (A) Previous Social Fund Loan? Yes Details of any action known to be taken to against applicants to recover amounts owed during the past 5 years (Eg,IVA,bankruptcy,default,CCJs,Bailiffs) 4

5 This is an accurate record of my financial position as at / /20 Additional tes on Interview (to be completed by CU) Applicant s Signature: Credit Union Application Tracking Form Eligibility and Identification CLIENTS NAME LOAN REF NO Client is an existing member of the credit union (Active Account /Dormant Account ) Client lives/works in the Credit Union bond area Client is not a member Application Form completed Acceptable forms of ID presented: These must include proof of permanent home address (e.g. utility bill, pension or benefits book, rent book or similar documentation) and proof of identity (e.g. passport, driving licence, travel pass or similar documentation that has a signature or photograph). Original documents seen: Name- item Name- item Item Ref number Item Ref number Client meets the low income criteria for qualification for a loan Amount Description Total Circumstances Client made aware of payment methods: Standing Order, Direct Debit, Cash or cheques Client has a bank account which will permit Standing Orders or Direct Debit Yes Client informed how to set up standing order or direct debit, information sheet issued If client does not have a bank account, leaflet on how to open a bank account given to client Signed by Client as confirmation that information above is accurate and correct: Signed: Date / /20 5

6 The following section to be completed by Credit Union worker Loan Amount Approved --- Application referred to Credit Unions Loans Committee for final approval of the loan and acceptance of membership to the Credit Union Application has been refused, amended or withdrawn prior to loan being issued: Details: A loan agreement document, schedule of repayment and loan disbursement cheque will be prepared for issue to the successful applicant DATE ISSUED: / /20 6

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