HOPI CREDIT ASSOCIATION

P.O. Box 1259 Keams Canyon, AZ 86034

(928) 738-2205/(800) 516-9091/Fax (928) 738-5633

Applicant – white areas Co-Applicant – gray areas

Primary applicant must be a member of the Hopi Tribe.

1 APPLICANT INFO.	Name of Applicant (Last, First, Middle Initial)	Social Security Number - -				Hopi Tribal Enrollment No.:
		Date of Birth
	Name of Co-Applicant (Last, First, Middle Initial)	Social Security Number - -				Tribal Enrollment No.: Hopi: Yes No Other Tribe:
		Date of Birth
	Home Mailing Address (P.O. Box) (City)						(State/Zip)

	Home Telephone Number		Years at Address				Number of Dependants
	Physical Address (St. Route No., Milepost No., etc.)				Email Address
ALL INCOME MUST BE VERIFIED WITH CHECKSTUBS, STATEMENTS, BOOKEEPING RECORDS, ETC.
2 INCOME INFO. Income from alimony, child support, or maintenance payments need not be revealed, if you do not choose to disclose such income in applying for credit. As a creditor, we may inquire whether any income stated in an application is derived from such a source.	Applicant’s current employer name and address (If Self Employed attach documentation for the prior year)							TITLE
	Business Telephone Number			How long employed? (yrs/mos)				Monthly Gross $	Monthly Net $
	Other Income (state if monthly or annual)/ Source of other income $ /			Previous Employer How long employed /
	Co-Applicant’s current employer name and address (If Self Employed attach documentation for the prior year)							TITLE
	Business Telephone Number			How long employed? (yrs/mos)				Monthly Gross $		Monthly Net $
	Other Income (state if monthly or annual)/ Source of other income $ /			Previous Employer How long employed /

3 CREDIT HISTORY	If a “yes” answer is given to a question, explain on an attached sheet.	Applicant		Co-Applicant
		YES	NO	YES	NO
	Are you a party in a lawsuit?
	Have you ever had credit under another name?
	Are you a co-maker, co-signer or guarantor on any loan? (Are you obligated for any other loans not in your name?)

REFERENCES

Name and Address of nearest relative not living with the applicant

Relation

Home Phone

Name and Address of nearest relative not living with the co-applicant

Relation

Home Phone

5 MONTHLY EXPENSES	HOUSEHOLD EXPENSES		CREDIT OBLIGATIONS
	EXPENSE	$ Per Month	OPEN ACCOUNTS	$ BALANCE	$ MONTHLY
	Rent (quarters, HUD Pymt, Apt.)		Charge Accounts, Credit Cards & Other Loans
	Groceries/Household Supp./Toiletries		1.
	Fuel (Propane)		2.
	Electricity		3.
	Phone		4.
	Water		5.
	Trash		6.
	Satellite Programming/Cable		Auto Loans
	Automobile Insurance		1.
	Child Care		2.
	Education (tuition, etc.)		Real Estate (Home/Mobile Home)
	Property/Health/Life Insurance		1.
	Alimony/Child Support		2.
	Self Employment Supplies		Other/Additional Liabilities (401K loans, etc)
	Other Monthly Expenses, please list (hay, feed, etc.)		1.
			2.
			3.
			4.
			5.
			6.
	TOTAL HOUSEHOLD EXPENSES	$	TOTAL CREDIT OBLIGATIONS	$	$

COLLATERAL

INFORMATION

NOTE:

Home Construction

& Mobile Home Loans will use home as collateral

COLLATERAL INFORMATION- Please list items you would use as collateral if approved. Collateral must equal the amount of the loan requested, collateral can be items such as:

· Personal Property (furniture, appliances, electronics, arts & crafts, traditional clothing, etc.)

· Automobile (free of liens, proof of insurance)

· Home/Mobile Home (free of liens, proof of insurance)

· Farm/Ranching Equipment (horse trailer, tractors, etc.)

Description Value

................................................................... $___________

Applicant agrees to notify the Hopi Credit Association (HCA) of any changes in name, address, employment, or any other important financial changes immediately. Applicant also agrees that everything stated in this application is true and correct to the best of the applicant’s knowledge and that the above information is a complete listing of all debts and obligations. Applicant also authorizes the HCA to obtain a credit report for credit update, renewal or extension of credit received. Applicant may request the name and address of the credit bureau from which a report was received.

Applicants Signature

Co-Applicants Signature

Social Security Number

Date of Birth

Social Security Number

Date of Birth

EXPENSE

$ Per Month

OPEN ACCOUNTS

Rent (quarters, HUD Pymt, Apt.)

Electricity

Alimony/Child Support

Self Employment Supplies

Other/Additional Liabilities (401K loans, etc)

2.

TOTAL CREDIT

OBLIGATIONS

Description Value

Date