Patriot Act Information Form

[Pages:1]PATRIOT ACT INFORMATION FORM

Contract Administrator: __________________________

Federal law requires all financial institutions to obtain, verify, and record information that identifies every customer. When applying for a loan, applicants will be asked for their name, address, date of birth, and other information that will allow lenders to identify them. Applicants will also be asked to show their driver's license or other identifying documents.

COMPLETION OF THIS FORM IS REQUIRED IN ORDER TO COMPLY WITH THE PATRIOT

ACT. A COPY OF THIS COMPLETED FORM MUST BE PLACED IN THE LOAN FILE.

Required Information:

Borrower Name:

_____________________________________

Co-Borrower Name:

_____________________________________

Borrower Date of Birth:

_____________________________________

Borrower SSN:

_____________________________________

Co-Borrower Date of Birth:

_____________________________________

Co-Borrower SSN:

_____________________________________

Borrower Current Physical Address: _____________________________________

Co-Borrower Current Physical Address: _____________________________________

Method Of Identification For Borrower (Only One Form Of Verification Is Required):

(1) Driver's License: State _______ # _______________ Issue Date: _______ Expir. Date: _______ (2) Passport: # _______________ Country: __________ Issue Date: _______ Expir. Date: _______ (3) Military ID: Country: __________ Expir. Date: _______ (4) State ID: # _______________ Issue Date: _______ Expir. Date: _______ (5) Green Card: Country: __________ #: ____________________ Expir. Date: _______ (6) Immigration Card: Country: __________ # _______________ Expir. Date: _______ (7) Gov't ID (Visa): #_______________ Expir. Date: _______ Gov't Branch: _______________

Method Of Identification For Co-Borrower (Only One Form Of Verification Is Required):

(1) Driver's License: State _______ # _______________ Issue Date: _______ Expir. Date: _______ (2) Passport: # _______________ Country: __________ Issue Date: _______ Expir. Date: _______ (3) Military ID: Country: __________ Expir. Date: _______ (4) State ID: # _______________ Issue Date: _______ Expir. Date: _______ (5) Green Card: Country: __________ #: ____________________ Expir. Date: _______ (6) Immigration Card: Country: __________ # _______________ Expir. Date: _______ (7) Gov't ID (Visa): #_______________ Expir. Date: _______ Gov't Branch: _______________

Resolution Of Any Discrepancy: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ____________________________________________________________________________

I/we acknowledge that I/we received a copy of this disclosure.

Applicant

Date Applicant

Date

Applicant

Date Applicant

Date

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