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Disclosures

A copy of this application will be retained by the lender, even if the loan is not granted. I/We understand that it is a federal crime punishable by fine or imprisonment, or both, to knowingly make any false statements concerning any of the above facts as applicable under the provisions of Title 18, United States Code, Section 1014. Everything that I have stated in this application is correct to the best of my knowledge. I understand that you will retain this application whether or not it is approved. You are authorized to check my credit and employment history and to answer questions about your credit experience with me. I authorize you to send information from time to time about services that you offer. If I do not want to receive that information, then I will contact you and you will remove my name from mailing list.

BY CLICKING ON THE SUBMIT BUTTON BELOW, I (WE) APPLY FOR THE LOAN AND/OR DEPOSIT PRODUCTS LISTED ABOVE AND CERTIFY THAT ALL INFORMATION PROVIDED ABOVE IS CORRECT AND AUTHORIZE YOU TO CHECK MY (OUR) CREDIT AND VERIFY THE INFORMATION PROVIDED IN THIS APPLICATION. I (WE) ALSO CERTIFY UNDER PENALTY OF PERJURY THAT THE SOCIAL SECURITY NUMBER(S) PROVIDED ABOVE IS/ARE CORRECT AND THAT I AM NOT (WE ARE NOT) SUBJECT TO BACKUP WITHHOLDING UNDER THE INTERNAL REVENUE CODE. I (WE) UNDERSTAND THAT ADDITIONAL INFORMATION MAY BE REQUIRED BEFORE A DECISION CAN BE MADE REGARDING THIS APPLICATION. I (WE) FURTHER UNDERSTAND THAT APPROVAL BY FIRST STATE FOR ANY OF THE LOAN OR DEPOSIT PRODUCTS IS CONDITIONED ON MY (OUR) AGREEMENT TO ABIDE BY ALL TERMS AND CONDITIONS CONTAINED IN THE APPLICABLE LOAN AGREEMENT AND/OR DEPOSIT AGREEMENT. I FURTHER AGREE TO RETURN ANY ACCESS DEVICE FOR OBTAINING FUNDS FROM ANY TYPE OF ACCOUNT UPON DEMAND BY FIRST STATE.


I HAVE READ THE ABOVE STATEMENT AND AGREE TO THE TERMS SET OUT THEREIN.

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