Midland National Bank
527 N. Main Street, P.O. Box 427
Newton, Kansas 67114
(316) 283-1700 / (800) 810-9457
Member FDIC  /  Equal Housing Lender
PLEASE NOTE: Midland National Bank is located solely within the state of Kansas, county of Harvey, USA. Our natural trade area includes Harvey county and all neighboring counties (Sedgwick, Reno, Butler, McPherson and Marion). If you are not within our natural trade area, please call us at (316) 283-1700 to request further information.

HOME EQUITY LINE OF CREDIT APPLICATION
 
Individual Credit Joint Credit

Click here if you are applying for individual credit. This means you are applying in your own name and are relying on your own income or assets, NOT those of another person as the basis for repayment.

 Click here if you are applying for joint credit with another person and will be relying on both your and their income or assets as the basis for repayment.
  We intend to apply for joint credit.
  Applicant's initials:

(please initial)
  Co-Applicant:

(please initial)
Please complete only the "Applicant Information" section. Please complete both the "Applicant Information" and the "Co-Applicant Information" sections.
I am applying for a Home Equity Line of Credit. The collateral property is my:
Property Address:   Market Value: $
Mortgage Balance:   Monthly Payment:   Escrow? YesNo
Date of Purchase:   Purchase Price:
Purpose of Loan:   Term:
Requested Loan Amount: $
Applicant Information
Primary Applicant's Name: Date of Birth:
Social Security Number:   Years of School:
If applying for secured credit, please indicate marital status: Married   Unmarried   Separated
Number of Dependents:   Ages of Dependents:
Present Address:
City:   State:   Zip Code:
Home Phone:  
Years at Present Address:    Own   Rent
Previous Address:
City:   State:   Zip Code:
Years at Previous Residence:    Owned   Rented
Current Employment Information
Present Employer: Self Employed
Employer Address:
Employer City:   State:   Zip Code:
Employer Phone:
Years with Present Employer:   Title:
Start Date:
Previous Employment Information
Previous Employer:   Self Employed
Previous Employer Address:
City:   State:   Zip Code:
Previous Employer Phone:
Years with Previous Employer:   Title:
Start Date:   End Date:   Monthly Gross Income:
Co-Applicant Information
Co-Applicant's Name:   Date of Birth:
Social Security Number:   Years of School:
If applying for secured credit, please indicate marital status: Married   Unmarried   Separated
Number of Dependents:   Ages of Dependents:
Present Address:
City:   State:   Zip Code:
Home Phone:  
Years at Present Address:    Own   Rent
Previous Address:
City:   State:   Zip Code:
Years at Previous Residence:    Owned   Rented
Current Employment Information
Present Employer: Self Employed
Employer Address:
Employer City:   State:   Zip Code:
Employer Phone:
Years with Present Employer:   Title:
Start Date:
Previous Employment Information
Previous Employer: Self Employed
Previous Employer Address:
City:   State:   Zip Code:
Previous Employer Phone:
Years with Previous Employer:   Title:
Start Date:   End Date:   Monthly Gross Income:
Primary Applicant & Co-Applicant Income Information
Primary Applicant's Gross Monthly Income: $  Other Income: $
Notice: Alimony, Child Support, or separate maintenance income need not be revealed if the Applicant or Co-Applicant does not choose to have it considered for repaying this loan
Co-Applicant's Gross Monthly Income: $   Other Income: $
Notice: Alimony, Child Support, or separate maintenance income need not be revealed if the Applicant or Co-Applicant does not choose to have it considered for repaying this loan
Primary Applicant & Co-Applicant Assets and Liabilities
Assets
Bank Accounts
Bank Name / Address Account # Current Balance
1.
2.
3.
4.
Automobiles
Automobile Make / Model Year Current Value
1.
2.
3.
4.
Stocks, Bonds & Other Assets
Stocks and Bonds Description: Value:
Stocks and Bonds Description: Value:
Retirement Accounts: Value:
Other Assets: Value:
Other Assets: Value:
Other Assets: Value:
Liabilities
Company / Debtor Account # Monthly Payment Unpaid Balance
Do you currently make Alimony, Support or Maintenance Payments?
Primary Applicant Amount Paid Frequency
Alimony Weekly  Monthly
Support Weekly  Monthly
Maintenance Weekly  Monthly
     
Primary Applicant Amount Paid Frequency
Alimony Weekly  Monthly
Support Weekly  Monthly
Maintenance Weekly  Monthly
General Information
If you or a joint applicant or other party answers "yes" to any of the following questions, please explain in the space provided.
Are you a guarantor or co-maker of any leases, contract or debts? (If "Yes", please describe)
Primary Applicant: Yes   No   Co-Applicant: Yes    No
Are there any suits or judgments against you? (If "Yes", please include amount)
Primary Applicant: Yes   No   Co-Applicant: Yes    No
Have you been declared bankrupt in the last 10 years? (If "Yes", please describe)
Primary Applicant: Yes   No   Co-Applicant: Yes    No
CREDIT DISCLOSURES: An insurance product may be offered with this product. If an insurance product is offered an extension of credit cannot be conditioned on either of the following: (1) Your purchase of an insurance product from this Bank or any of our affiliates; or (2) Your agreement NOT to obtain, or a prohibition on you from obtaining, an insurance product from an unaffiliated entity. By signing this Application you agree that you have read and understand these Disclosures.
Authorization & Signature(s)
Applicant Signature:      Date:
Co-Applicant Signature:    Date:
 
If you would like to receive e-mail confirmation and notification of your application status, please indicate below. We will use the email address you supplied in the application above. (You will still receive some communication via US Mail.) You will receive confirmation of your application within one business day.
Yes. Send me e-mail notification of my application status.  No. Do not send me e-mail notification.
By submitting this form I/we, the above named applicant(s), specifically acknowledge and agree that: (1) the loan requested by this application will be secured be a first mortgage or deed of trust on the property described herein; (2) the property will not be used for any illegal or prohibited purpose or use; (3) all statements made in this application are made for the purpose of obtaining the loan indicated herein; (4) occupation of the property will be as indicated above; (5) verification of reverification of any information contained in the application may be made at any time by the Lender, its agents, successors and assigns, either directly or through a credit reporting agency, from any source named in this application, and the original copy of this application will be retained by the Lender, even if the loan is not approved; (6) the Lender, its agents, successors and assigns will rely on the information contained in this application and 1/we have a continuing obligation to amend and/or supplement the information provided in this application if any of the material facts which I/we have represented herein should change prior to closing; (7) in the event my/our payments on the loan indicated in this application become delinquent, the Lender, its agents, successors and assigns, may, in addition to all their other rights and remedies, report my/our name(s) and account information to a credit reporting agency; (8) ownership of the loan may be transferred to successor or assign of the Lender without notice to me and/or the administration of the loan account may be transferred to an agent, successor or assign or the Lender with prior notice to me; (9) the Lender, its agents, successors and assigns make no representations or warranties, expressed implied, to the Applicant(s) regarding the property, the condition of the property, or the value of the property.
CERTIFICATION:  I/We certify that the information provided in this application is true and correct as of the date of submittal of this application and acknowledge my/our understanding that any intentional or negligent misrepresentation(s) of the information contained in this application may result in civil liability and/or criminal penalties including, but not limited to, fine or imprisonment or both under the provisions of Title 18, United States Code, Section 1001, et seq. and liability for monetary damages to the Lender, its agents, successors and assigns, insurers and any other person who may suffer any loss due to reliance upon any misrepresentation which I/we have made in this application.
By clicking the "Submit Application" button below, I certify that everything I have stated in this application and on any attachments is correct.  The Bank may keep this application whether or not it is approved.  By typing and submitting this form, I authorize Midland National Bank to check my credit and employment history, to have a consumer credit report prepared on me for the purpose of evaluating this application for credit, and to answer questions others may ask about my credit record with Midland. Midland National Bank may rely on such information to make credit decisions concerning my loan. I agree to notify Midland National Bank of any adverse change in my financial condition.