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PERSONAL DETAILS Title: _____ Forename(s): ____________________________ Surname: ________________________ Date of birth: _______________________________________Address: __________________________________________ ___________________________________________________Postcode: __________________________________________Length of time at current address: ____________________________________________Previous Address: _______________________________________________________________________________________(if less than five years) __________________________________________________________________________________________________________________________________________________________________________________________Telephone: _________________________________ Mobile No: ____________________________________________Marital Status: Single / Married / Divorced / Widowed / Separated / Co-habiting Residential Status: Home owner / LA-HA Tenant / Private Tenant / with Parents / Other Employment Status: Employed (FT) / Employed (PT) / Self-employed / Unemployed / Retired Number of dependants: ______________________ Age(s): ________________________________________________Bank Account: ______________________Sort Code: _______________ Account Number: ___________________________LOAN REQUIREMENTS & DECLARATIONAmount of Loan Requested: ? ________________Reason for Loan: _____________________________________Amount of Existing Loan outstanding ? __________________________________________________Proposed payment terms: Amount ? ___________________ over ________________ weeks / fortnights / months.3891579123696800736536561087000Data Protection Statement: In accordance with the principles of the Data Protection Act 1998, I understand that the Northumberland Community Bank will use my personal details for the purposes of managing my accounts with the Northumberland Community Bank. All information will be treated confidentially and will only be shared with other agencies for the purposes of credit referencing and debt recovery (for which purposes we hold a category F consumer credit licence), in the public interest and, or prevention of fraud by order of the Courts. I also understand that I am entitled to a copy of the information held about me by applying in writing and that there is a fee for this. We may at times use your details to keep you informed of services available from the Northumberland Community Bank. If you do not wish your details to be used for this purpose, please tick this box. Statement of Insurability: I declare that to the best of my knowledge, I do not have a life threatening condition; I understand that making a false declaration may affect any insurance claim.APPLICANTS DECLARATION: I submit this application for a Northumberland Community Bank loan and declare that the information is true and accurate. I authorise you to make any enquiries you feel necessary for the confirmation of the information contained herein, the credit agreement and for credit assessment purposes (including those below). I agree that this Northumberland Community Bank may carry out searches against me at credit reference agencies and agree that details of such searches will be added to the agencies’ records about me and may be seen by other organisations making searches. I also agree and acknowledge that information held about me by the agencies may be linked to records relating to any person with whom I am linked financially. I agree that if I default on repayments, information about my loan may be passed to the Department for Works and Pensions for their consideration of deductions from benefits that I am, or will become, entitled to. I also agree that an attachment of earnings may be applied in the event that I default on repayments.Applicants Name: _____________________________________________________________________Applicants Signature: _________________________________________ Date: ____________________ FINANCIAL STATEMENT IncomeWeekly ?Fortnightly ?Monthly ?Evidence SeenSalary / WagePartners IncomeBenefitsPensionTax CreditsOtherTotal?ExpenditureWeeklyFortnightlyMonthly Evidence SeenRent/MortgageCouncil TaxElectric / GasTelephoneGroceriesCatalogues / Credit Cards Hire Purchase/ RentalsLoan RepaymentsFares/PetrolClothingWater RatesSavings/InvestmentsInsurance(s)TV LicenceEntertainmentInternet/ B>BandMobileDVLATotal? Bad Debts: Yes / No County Court Judgements: Yes / No If yes please state details below.EXISTING CREDIT COMMITMENTSCreditor: ________________________ Loan in Arrears: Yes / NoDate loan began: _________________Repayment amount/ weekly/fortnightly/monthly ?_______________ ________________ W / F / MAmount Outstanding ? __________________Creditor: ________________________ Loan in Arrears: Yes / NoDate loan began: _________________Repayment amount/ weekly/fortnightly/monthly ?_______________ ________________ W / F / MAmount Outstanding ? __________________Creditor: ________________________ Loan in Arrears: Yes / NoDate loan began: _________________Repayment amount/ weekly/fortnightly/monthly ?_______________ ________________ W / F / MAmount Outstanding ? __________________FURTHER EVIDENCE NEEDED Y / N3 Months Bank Statements Existing Credit CommitmentsProof of BenefitsPIP LetterInterviewed by: ______________________________All Evidence Received? Date: __________________ ................
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