Funeral Financing Loan Application

Name of Deceased*

First Name Last Name

Funeral Home Provider*

Type of Service*

BurialCremation

Name of your Funeral Director*

First Name Last Name

Applicant Name*

First Name Last Name

My Birth Date*

Month Day Year

My Social Security Number*

My Email*

example@example.com

My Phone Number*

My Home Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Number of Years at Current Home Address: *

Am I Currently Employed?*

YesNo

Number of Years at Current Employer: *

If not employed enter "0"

Amount of Loan Request*

Minimum of $2,500 and up to $25,000

My Gross Annual Income*

Alimony, child support or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.

My Current Monthly Rent/Mortgage*

My Other Monthly Loan or Debt Payments*

EXCLUDING MONTHLY RENT/MORTGAGE

Name of Bank*

ABA Routing Number*

Name on Account*

First Name Last Name

Account Number*

Retype Account Number*

Photo ID (Driver's License, State ID, Passport) *

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Release of Information*

The undersigned hereby authorizes Huntingdon Valley Bank to release such information and records to the Funeral Home Provider listed herein necessary for the successful review of this application including status of credit decision, all information required to complete application, and all information regarding documentation and disbursements.

FCRA Consent*

To all consumer-reporting agencies and all creditors and depositories of the undersigned, please be advised that the undersigned has made an application to Huntingdon Valley Bank ("Lender") for a request of an extension of credit. Therefore, the undersigned hereby authorizes Lender to make all inquiries it deems necessary to verify accuracy and determine the undersigned’s creditworthiness. The Lender is authorized to obtain any information it feels necessary in processing this application. The undersigned also authorizes Lender to disclose any deposit or credit experiences with the undersigned to third parties. In addition, the undersigned hereby authorizes Lender to disclose to any third party, or any agent or employee thereof, information regarding the deposit or credit experience with the undersigned.

The undersigned certifies that the statements made on the application and the other information provided in connection with this application are true and complete. The undersigned agrees to promptly notify the Lender of any material changes to this information. The applicant understands that all fees, including commitment and documentation fees and annual credit review fees are non-refundable. The electronic signature of the undersigned below may be deemed equivalent to an original.*

Clear

Family Shield Credit

Bank Account Information for Monthly Loan Payments