Welcome to Louisiana Public Health Workers FCU

Secure Loan Application

Fleur de Lis Federal Credit Union 433 Metairie Rd. Suite 114 Metairie, Louisiana 70005

Married applicants may apply for a separate account. If you are applying for Individual Credit, you must complete the Applicant section
about yourself and the Co-Applicant section about your spouse if:

Your spouse will use the account, or
You are relying on your spouse's income as a basis for repayment.

If you are relying on income from alimony, child support or separate maintenance, complete the Co-Applicant section to the extent
possible about the person on whose payments you are relying.

If you are applying for Joint Credit with another person, complete the Applicant and Co-Applicant sections.

TYPE AND AMOUNT OF CREDIT YOU'RE REQUESTING

Is this your first loan from us?	Yes No
How were you referred for this loan? (check all that apply)	Email Friend Family Branch Ad’s Newsletter Web Site Home Banking Other(Explain)
Amount/Credit Limit Requested:	$
Approximate Time to Repay:	How Many? Periods:
Loan Type:
Loan Purpose:
Security Offered:	(for secured credit only)
Type of Credit:	Individual Joint

PAYMENT PROTECTION COVERAGE
Check if desired

Find out more about Payment Protection Insurance and why it's a better consumer value when offered through your credit union.

Check coverage(s) desired. We will disclose the cost of this Payment Protection Insurance - Credit Disability and Credit Life - to you.
A separate enrollment form which discloses the terms and conditions must be signed for coverage to become effective.

Yes
No

Do you want your loan protected for you and your family if you become disabled?

TELL US ABOUT YOURSELF

Applicant

Co-Applicant

Name:
Email:

Name:

CU Account #:

Social Security #:

Please indicate your marital status if you are applying for Joint Credit, secured credit or if you live in a community property state:
Married
Separated
Unmarried (Single - Divorced - Widowed)

Driver's License #: State:

Birth Date:

Spouces Name:
Social Security #:

Home Phone:
Business Phone:

Present Address:

Years There: Own Rent

DEBTS

Mortgage/Rent owed to:

Balance (Mortgage only):

Monthly Payment:
Current APR % (Mortgage only):

Person Responsible for Payment:

Auto Loan Owed To:
Auto Loan Monthly Payment:
Auto Loan Balance Due:
Credit Card Owed To:
Credit Card Monthly Payment:
Credit Card Balance Due:
Credit Card Owed To:
Credit Card Monthly Payment:
Credit Card Balance Due:
Credit Card Owed To:
Credit Card Monthly Payment:
Credit Card Balance Due:
Other Debts Owed To:
Other Debt – Type:
Other Debt Monthly Payments:
Others Debt Balance Due:
Alimony/Child Support Payments:

Auto Loan Owed To:
Auto Loan Monthly Payment:
Auto Loan Balance Due:
Credit Card Owed To:
Credit Card Monthly Payment:
Credit Card Balance Due:
Credit Card Owed To:
Credit Card Monthly Payment:
Credit Card Balance Due:
Credit Card Owed To:
Credit Card Monthly Payment:
Credit Card Balance Due:
Other Debts Owed To:
Other Debt – Type:
Other Debt Monthly Payments:
Others Debt Balance Due:
Alimony/Child Support Payments:

INCOME

Employer:

Occupation:

Date of Employment:

Supervisor:

Income: $ Net
Gross
Annual
Monthly
Bi-weekly
Weekly

Other Income: (Notice: Alimony, child support or separate maintenance income need not be revealed if you do not have it considered as a basis for repaying this obligation.)
Source:
$
Annual
Monthly
Hourly

Have you had one or more outstanding judgments? Yes No To Whom(Name of Creditor)	Have you had one or more outstanding judgments? Yes No To Whom(Name of Creditor)
In the last 10 years, have you been declared bankruptcy or had a debt adjustment plan? Yes No	In the last 10 years, have you been declared bankruptcy or had a debt adjustment plan? Yes No
Have you had a foreclosure or repossession in the last 7 years? Yes No To Whom(Name of Creditor)	Have you had a foreclosure or repossession in the last 7 years? Yes No To Whom(Name of Creditor)
Are you a party in a lawsuit? Yes No	Are you a party in a lawsuit? Yes No
Are you other than a U.S. citizen or permanent resident alien? Yes No	Are you other than a U.S. citizen or permanent resident alien? Yes No
Is your income likely to reduce in the next two years? Yes No	Is your income likely to reduce in the next two years? Yes No
Are you a co-maker, co-signer, or guarantor on any loan not listed above? Yes No For Whom(Name of Others Obligated on Loan) To Whom(Name of Creditor)	Are you a co-maker, co-signer, or guarantor on any loan not listed above? Yes No For Whom(Name of Others Obligated on Loan) To Whom(Name of Creditor)

References:	References:
Name Nearest Relative:	Name Nearest Relative:
Address:	Address:
Relationship:	Relationship:
Phone Number:	Phone Number:
Name Closest Friend:	Name Closest Friend:
Address:	Address:
Phone Number:	Phone Number:

You must submit copies of your latest two (2) paycheck stubs or recent w-2 to the credit union by mail, fax or personally.

By submitting this loan request, you agree that the information is correct to the best of your knowledge. You also agree to notify
us of any changes to your name, address or employment.

You authorize the credit union to obtain credit reports in connection with this request.

Please only submit your loan application one time.
If the Credit Union needs any additional information after receiving your application, we will contact you.
Thanks for your cooperation!