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Honesdale National Bank
Home Equity Loan Application

Privacy Policy:
Our privacy policy protects the privacy of your personally-identifying information that you provide us online.

Applicants must reside in Northeastern PA, Sullivan County New York or Delaware County New York.

Important Information about Procedures for Opening a New Account
Identification Procedures Requirements: 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.

What this means for 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 may also ask to see your driver's license or other identifying documents.

Security Notice:
You should ONLY fill out this form on-line if you are using a browser with the latest security enhancements. If you don't have the latest version, download a copy now. This form is NOT cached (saved in your computer's memory) when you QUIT your browser.

Instructions:
1. Print this loan application and gather the information you'll need.
2. Complete application on-line and click "Submit Application" or fax it to 570-253-5263.
3. To safeguard your privacy, QUIT your browser and restart it again after using this form.


This loan application is for personal loans only and is NOT intended for commercial use. A valid social security number is required to apply. Please review and gather the information you will need before completing this form. Upon receipt of the application, we will send you the proper disclosures.

Home Equity Loan Request
Amount Requested:
Type of Application: Individual Applicant Joint Applicant

Applicant
First Name
Middle Initial
Last Name
Date of Birth
Social Security No.
No. of Dependents
Driver's License No.
Driver's License State
Your E-mail Address
Home Phone
Best Time To Call
Work Phone
Are there any unsatisfied Judgments against you? Yes No
Have you been declared bankrupt in the last 7 years? Yes No

Residence
Your Primary Residence:
Own with Mortgage Own Clear Rent Other
Present Street Address
City
State
Zip
Years At Present Address
Your Monthly Rent or Mortgage Payment
Years At Previous Address
Your Previous Address

Home Information
Collateral Property Address (If different from above)
Date Purchased
Current Mortgage Holder
Mortgage Holder Phone
Purchase Price
Market Value
Mortgage Balance

Employment
Employed Self-Employed Retired Unemployed Student
Your Present Employer
Phone
Street Address
City
State
Zip
Gross Monthly Salary
Your Positon
Years There
You do not have to list alimony, child support or separate maintenance income unless you want us to consider it for the purposes of granting and repayment of this credit request.
Other Monthly Income
Source of Other Income
Previous Employer
(if less than 3 years at current employer)
Years at
Previous Employer
Street Address
City
State
Zip

Additional Information
Your Checking Account Number
Institution Name
Your Savings Account Number.
Institution Name
Name of Creditor
Approx. Balance
Monthly Payment
Collateral, if any
Total Amount of "Other" Monthly Payments not listed above:
Assets
Value
Title Held Name

Co-Applicant
First Name
Middle Initial
Last Name
Date of Birth
Social Security No.
No. of Dependents
Driver's License No.
Driver's License State
Your E-mail Address
Home Phone
Best Time To Call
Work Phone

Co-Applicant Residence
Your Primary Residence:
Own with Mortgage Own Clear Rent Other
Present Street Address
City
State
Zip
Years At Present Address
Your Monthly Rent or Mortgage Payment
Years At Previous Address
Your Previous Address

Co-Applicant Home Information
Collateral Property Address (If different from above)
Date Purchased
Current Mortgage Holder
Mortgage Holder Phone
Purchase Price
Market Value
Mortgage Balance

Co-Applicant Employment
Employed Self-Employed Retired Unemployed Student
Your Present Employer
Phone
Street Address
City
State
Zip
Gross Monthly Salary
Your Positon
Years There
You do not have to list alimony, child support or separate maintenance income unless you want us to consider it for the purposes of granting and repayment of this credit request.
Other Monthly Income
Source of Other Income
Previous Employer
(if less than 3 years at current employer)
Years at
Previous Employer
Street Address
City
State
Zip

Co-Applicant Additional Information
Your Checking Account Number
Institution Name
Your Savings Account Number.
Institution Name
Name of Creditor
Approx. Balance
Monthly Payment
Collateral, if any
Total Amount of "Other" Monthly Payments not listed above:
Assets
Value
Title Held Name

Information For Government Monitoring Purposes
This section to be completed only for loans subject to reporting under the Home Mortgage Disclosure Act (HMDA).

HMDA loans are loans made for the following purposes: Home Purchase (secured), Home Improvement (secured or unsecured), or refinance of a loan secured by a 1-4 residential dwelling (regardless of purpose).

The following information is requested by the Federal government for certain types of loans related to a dwelling, in order to monitor the Lender's compliance with equal credit opportunity, fair housing and home mortgage disclosure laws. You are not required to furnish this information, but are encouraged to do so. The law provides that a Lender may discriminate neither on the basis of this information, nor on whether you choose to furnish it.

If you choose to furnish the information, please provide both ethnicity and race. For race, you may check more than one designation. If you do not furnish ethnicity, race, or sex, under Federal regulations, this Lender is required to note the information on the basis of visual observation or surname.

If you do not wish to furnish the above information, please check the box below. (Lender must review the above material to assure that the disclosures satisfy all requirements to which the Lender is subject under applicable state law for the particular type of loan applied for.)

Applicant:
I do not wish to furnish this information.

Ethnicity:
Hispanic or Latino
Not Hispanic or Latino

Race or National Origin:
American Indian, Alaskan Native
Asian
Native Hawaiian or other Pacific Islander
White
Black or African American

Sex:
Female Male
Co-Applicant:
I do not wish to furnish this information.

Ethnicity:
Hispanic or Latino
Not Hispanic or Latino

Race or National Origin:
American Indian, Alaskan Native
Asian
Native Hawaiian or other Pacific Islander
White
Black or African American

Sex:
Female Male

Applicant(s) Statement
I/We have completed this request for credit in consideration of Honesdale National Bank lending to me and/or others upon my guarantee. I/We certify that all information contained herein is accurate and complete to the best of my knowledge.

I/We authorize Honesdale National Bank to retain property of this application, to rely on the foregoing, to check and verify my credit, employment and salary history, to secure follow up credit reports concerning my credit worthiness and to exchange information about my account with proper persons, creditors and credit bureaus.

I authorize my employer (present and future), bank and other references listed above to release and/or verify information to Honesdale National Bank at any time. I acknowledge that this application is subject to approval of credit and acceptance by Honesdale National Bank. Should my request for credit and subsequent loan be approved, I agree to give Honesdale National Bank written notice immediately upon change of my name, address, employment or any other pertinent information contained herein.

I/We AGREE with the above statement