USA PATRIOT ACT INFORMATION DISCLOSURE Important Information about Application Procedures 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 every customer. What this means to you: When you apply for a loan, we will ask 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.
Authorization to Release Financial Information : : Accountant: Lender: CBC National Bank 1887 South 14 th Street Fernandina Beach, FL 32034 In consideration of an extension of credit made to me by the Lender, I authorize any accountant or tax preparer, including but not limited to the Accountant named above, to provide CBC National Bank with tax returns, financial statements, or other financial information related to my personal finances or legal entities in which I have an ownership interest. I understand that this agreement will remain in force so long as I have any open credit facility with the Lender.
s Preference to Legal Counsel and Insurance Agent You have the right to select the legal counsel who shall represent you in all matters relating to the closing of a loan extended to you pursuant to this application and to select the homeowners insurance agent who is to furnish the insurance required in connection with the mortgage which shall secure the loan so extended. I/ We designate the following as legal counsel to represent me/us: Attorney name/address: I/We designate the following as insurance agent to provide insurance coverage: Insurance Agent s name/address:
COMMERCIAL APPLICATION NOTICE TYPE OF ACCOUNT REQUESTED Check one to indicate the type of account you are requesting. Note: married applicants may apply for separate accounts. Joint Account We intend to apply for joint credit. Applicant initials: Joint Applicant initials: Joint Applicant initials: Individual Account Relying solely on my income and assets. Individual Account Relying on my income and assets as well as income or assets of another. Application : Purpose of Loan: REAL ESTATE COLLATERAL You have the right to a copy of the appraisal report used in conjunction with your application for credit if your loan is to be secured by a 1-4 family dwelling. If you wish a copy, please write to us at the mailing address we have provided. We must hear from you no later than 90 days after we notify you about the action taken on your credit application or you withdraw your application. In your letter, give us the following information: date of application, name of the applicant, property address and your current mailing address. CUSTOMER IDENTIFICATION 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, including loans. What this means to you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We will ask to see your driver s license or other identifying information. CREDIT DENIAL NOTICE If your gross revenues were $1,000,000.00 or less in your previous fiscal year, or you are requesting trade credit or similar type of business credit and if your application for business credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain the statement please contact the bank at the address provided within 60 days from the date you are notified of our decision. We will send you a written statement of the specific reasons for the denial within 30 days of receiving your request for the statement. EQUAL CREDIT OPPORTUNITY 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 the applicant has the capacity to enter into a binding contract), because all or part of the applicant s income is 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 this creditor is: Office of the Comptroller of the Currency 1301 McKinney Street, Suite 3450 Houston, Texas 77010 800-613-6743 I/we acknowledge below that I/we received a copy of this notice on this day of, 20 Applicant Joint Applicant Joint Applicant
NOTICE OF RIGHT TO RECEIVE COPY OF APPRAISAL You means the Applicant(s) and I/We means the Lender You have the right to a copy of the appraisal report used in connection with your application for credit. If you wish a copy, please write to us at the mailing address we have provided. We must hear from you no later than 90 days after we notify you about the action taken on your credit application or you withdraw your application. In your letter, please give us the following information: Loan or application number, if known, date of application, name(s) of loan applicant(s), property address, and your current mailing address. ACKNOWLEDGEMENT By signing below, you acknowledge that you have read and understood the Notice of your right to receive a copy of the appraisal.
Certification of Personal Financial Statement I/We hereby certify that the enclosed financial statement of Bank is intended for use by CBC National Bank, 1887 South 14 th Street, Fernandina Beach, FL 32034 for the purpose of obtaining credit for the Applicant(s) or for the purpose of the Applicant(s) guaranteeing credit for others. I/We further certify that all information contained therein is true and correct in every detail and represents the financial condition of the Applicant(s) on the date given below. CBC National Bank is authorized to make all inquiries deemed necessary to verify the accuracy of the information contained therein and to determine the creditworthiness of the undersigned. Applicant(s) will promptly notify CBC National Bank of any subsequent changes which would affect the accuracy of the enclosed statement. Applicant(s) are aware that any knowing or willing false statements regarding property values listed therein for purposes of influencing the actions of CBC National Bank can be a violation of federal law 18 U.S.C. sec. 1014 and may result in a fine or imprisonment or both. In addition, each individual signing below authorizes the CBC National Bank to check their individual credit account and employment history and have a credit reporting agency prepare a credit report on each. The undersigned declares that he/she has read and understands the statements above. Applicant Signature Applicant Signature
Personal Financial Statement as of NAME Applicant NAME Co-Applicant SOCIAL SECURITY # BIRTHDATE SOCIAL SECURITY # BIRTHDATE ADDRESS ADDRESS EMAIL ADDRESS EMAIL ADDRESS HOME PHONE OFFICE PHONE HOME PHONE OFFICE PHONE CELL PHONE FAX CELL PHONE FAX OCCUPATION LENGTH OF EMPLOYMENT OCCUPATION LENGTH OF EMPLOYMENT EMPLOYER EMPLOYER EMPLOYER S ADDRESS EMPLOYER S ADDRESS ACCOUNTANT NAME & PHONE ACCOUNTANT NAME & PHONE ATTORNEY NAME & PHONE ATTORNEY NAME & PHONE INSURANCE AGENT NAME & PHONE INSURANCE AGENT NAME & PHONE SALARIES Annual Income Annual Expenditures FEDERAL & STATE INCOME TAXES BONUSES/COMMISSIONS REAL ESTATE TAXES DIVIDEND/INTEREST INCOME INSURANCE RENTAL INCOME RENTAL PAYMENTS/MAINTENANCE CAPITAL GAINS MORTGAGE/LOAN PAYMENTS PARTNERSHIP INCOME ALIMONY/CHILD SUPPORT OTHER INCOME (SPECIFY) * TOTAL INCOME OTHER EXPENSES (SPECIFY) TOTAL EXPENDITURES * Alimony, child support, or separate maintenance income need not be revealed unless you wish to have it considered as a basis for repaying this obligation.
Assets Liabilities CASH IN CBC NATIONAL BANK CASH IN OTHER BANKS (NAME) REVOLVING CREDIT CARDS PAYABLE MARGIN ACCOUNTS PAYABLE (SCHEDULE B) OTHER ACCOUNTS PAYABLE (SCHEDULE C) NOTES & LEASES PAYABLE (SCHEDULE C) CASH VALUE OF LIFE INSURANCE (SCHEDULE A) MARKETABLE SECURITIES (SCHEDULE B) PERSONAL RESIDENCE (SCHEDULE D) OTHER REAL ESTATE OWNED (SCHEDULE D) CLOSELY HELD BUSINESS VENTURES (SCHEDULE E) MORTGAGES PAYABLE (SCHEDULE D) REAL ESTATE TAXES PAYABLE BUSINESS DEBT (SCHEDULE E) INCOME TAXES PAYABLE OTHER LIABILITIES (SPECIFY) IRA S/VESTED RETIREMENT ACCOUNTS PERSONAL PROPERTY (SCHEDULE G) OTHER ASSETS (SPECIFY) TOTAL ASSETS TOTAL LIABILITIES NET WORTH (Total Assets minus Total Liabilities) TOTAL CONTINGENT LIABILITIES (SCHEDULE F) SCHEDULE A CASH VALUE OF LIFE INSURANCE COMPANY OWNER BENEFICIARY FACE AMOUNT LOAN AMOUNT CASH SURRENDER VALUE SCHEDULE B MARKETABLE SECURITIES STOCKS # OF SHARES BONDS FACE VALUE OWNER DESCRIPTION PLEDGED Y/N COST MARKET VALUE Page 2 of 5
SCHEDULE C ACCOUNTS, NOTES & LEASES PAYABLE LENDER COLLATERAL TERMS MATURITY ORIGINAL BALANCE MONTHLY PAYMENT UNPAID BALANCE PROPERTY ADDRESS SCHEDULE D REAL ESTATE OWNED/MORTGAGES % OWNED DATE BOUGHT PRICE MONTHLY RENTAL INCOME MORTGAGE BALANCE MONTHLY PAYMENT MARKET VALUE TYPE OF BUSINESS/INVESTMENT SCHEDULE E CLOSELY HELD BUSINESS VENTURES* % OWNED TOTAL ASSETS TOTAL LIABILITIES LOANS PAYABLE MONTHLY PAYMENT MARKET VALUE *Please attach any financial statements/tax returns relevant to the partnership(s), LLC s, S-CORP s, etc. and include schedule K-1 s. Page 3 of 5
SCHEDULE F CONTINGENT LIABILITIES YES* NO AMOUNT Are you an endorser, co-maker, or guarantor on any debt for any individual or organization? Are you a defendant in any lawsuits or legal actions? Do you have any outstanding letters of credit or surety bonds? Are you a signer on any other leases or contracts? Are any of your state, federal or local tax obligations past due? Have you, or any organization in which you were part owner, declared bankruptcy within the past 10 years? Any other assets or liabilities not listed on schedules herein? Have you drawn a will? Please list executor and date: CONTINTENT LIABILITIES LOANS PAYABLE LENDER COLLATERAL TERMS MATURITY ORIGINAL BALANCE MONTHLY PAYMENT UNPAID BALANCE * If you answer yes to any of these questions, please give details sufficient to analyze your obligation. DESCRIPTION SCHEDULE G PERSONAL PROPERTY OWNED % OWNED ORIGINAL COST PURCHASE DATE FAIR MARKET VALUE BALANCE OWED LENDER The information herein and on all accompanying statements is provided for the expressed purpose of obtaining credit for the Applicant(s) or for others with the guarantee of the undersigned. The undersigned acknowledge that that all representations made in these statements will be relied upon by the Creditor in its decision to grant or continue extension(s) of credit. The undersigned represent that all information contained in these statements are true, correct and complete as of the date given below. The undersigned further attests that any material adverse change, to include name, address, employment and monetary asset or liability, will be reported to the Creditor within a reasonable period of time. In the absence of such notification of change, Creditor will consider the attached statements as continuing and substantially correct. If it is discovered that the information contained is not accurate in any material respect, and that notification has not been made, then the Creditor may proclaim the indebtedness of the undersigned, or the indebtedness guaranteed by the undersigned, immediately due and payable. Creditor is authorized to make all necessary inquiries, to include employment history and credit reporting agency credit reports, to verify the accuracy of the information contained herein and to further determine the credit worthiness of the undersigned. Creditor is further authorized to answer any questions about Creditor s experience with the undersigned. Also, by signing below, Applicant(s) acknowledge that any knowing or willful false statements herein made for the purpose of influencing the actions of the Creditor can be a violation of federal law 18 U.S.C. section 1014 and may result in a fine, imprisonment or both. APPLICANT SIGNATURE CO-APPLICANT SIGNATURE DATE DATE Page 4 of 5
RENT ROLL Property Address: : C.A.M. ANNUAL EXPENSE TENANT NAME UNIT # SQ FT RENT RECOVERY LEASE TERMS TOTAL: - $ - $ - Signature Page 5 of 5
DEBT SCHEDULE Entity Name: : Loan Original Current Loan Origination Amount Interest Monthly Loan Maturity Number Bank Borrowed Rate Payment Balance Collateral Description CONTINGENT LIABILITIES (Loans you personally guaranteed) Loan Original Current Loan Origination Amount Interest Monthly Loan Maturity Number Bank Borrowed Rate Payment Balance Collateral Description BY: Signature
Regulation B Notice to Apply for Joint Credit Notice: We intend to apply for Joint Credit. Acknowledgement: By signing below, we acknowledge the intention to apply for joint credit on today s date. X X X