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616-681-3551

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FINANCE REQUEST FORM

Personal Information

First Name:

Last Name:

Date of Birth:

Marital Status:

# of Dependents:

Address Information

Street Address:

Street Address 2:

City:

State:

Postal Code:

Email Address:

Home Phone:

Cell Phone:

Years live at current residence?

Residential Status:

Employment Information

Employer:

Street Address:

Street Address 2:

City:

State:

Postal Code:

Work Phone:

Occupation:

Self Employed?

Employed:

Gross Income / Month (Pre-Tax):

Other Income:

Other Income Source:

Relative Information

Relative First Name:

Relative Last Name:

Street Address:

Street Address 2:

City:

State:

Postal Code:

Home Phone:

Relation:

Reference Information

Reference First Name:

Reference Last Name:

Street Address:

Street Address 2:

City:

State:

Postal Code:

Home Phone:

Relation:

Credit Information

Down Payment:

Monthly Rent or Mortgage Payment:

Mortgage Balance:

Checking Account: Yes No

Savings Account: Yes No

Automobile Loan: Yes No

Other Loan: Yes No

Credit Card: Yes No

Has any party to the applicant been the subject of, or is subject to, any bankruptcy proceedings? Yes No

Has applicant or spouse ever obtained credit under a different name? Yes No

Has applicant or spouse ever had a vehicle repossessed? Yes No

2730 136th
Hopkins, MI 49328
p: 616-681-3551

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