Collateral Loan Application

							                                          Collateral Loan Application
   Individual Request      Joint Request
Applicant Info:
Full Name: _______________________________________ Date of Birth: _______________ SSN: ________________
   Married Unmarried Separated Number of Dependants Other Than Yourself: _________
Home Address: _________________________________________________________ Years at Current Address: ______
Home Phone: ___________________ Business Phone: _______________________ Cell/Other: ____________________
Applicant Identification:
Issuer: U.S. State U.S. Government Foreign Government Other (specify): ________________________________
I.D. Type: Driver’s License Passport Birth Certificate Military I.D. Other (specify): ______________________
I.D. Number: _________________ Issue Date: ___________ Exp. Date: ___________ Issued By: __________________

Co-Applicant Info:
Full Name: _______________________________________ Date of Birth: _______________ SSN: ________________
   Married Unmarried Separated Number of Dependants Other Than Yourself: _________
Home Address: _________________________________________________________ Years at Current Address: ______
Home Phone: ___________________ Business Phone: _______________________ Cell/Other: ____________________
Applicant Identification:
Issuer: U.S. State U.S. Government Foreign Government Other (specify): ________________________________
I.D. Type: Driver’s License Passport Birth Certificate Military I.D. Other (specify): ______________________
I.D. Number: _________________ Issue Date: ___________ Exp. Date: ___________ Issued By: __________________


Collateral Info:
  Savings Account or CD        Repayment Method: Principal & Interest or Interest Only Demand
Account Number: __________________ Current Balance: _____________ Date Opened: ____________
Total Amount to be financed: ____________Term Requested: _____
Maximum LTV not to exceed 95%, $50 admin fee applies

  Stock*
Exchange: _________ Symbol: _________ Stock Name: _________________ CUSIP Number: ________________
Number of Shares: ________ Price Per Share: __________ Value: ___________
Total Amount to be financed: ____________Term Requested: _____
*Customer must be in possession of stock certificate
Maximum LTV not to exceed 70%, $50 admin fee applies


Signatures: I certify that everything I have stated in this application and on any attachments are correct. You may keep
this application whether or not it is approved. By signing below I authorize Legacy Banks to check my credit and
employment history in connection with this application or for renewal or update purposes.

Applicant: ________________________________________                                Date _____________
Co-Applicant: _____________________________________                                Date______________

Bank Information:
Taken By: ___________________________ Branch: _____________________________ Date: ____________________
Existing Legacy Banks Customer:      Yes     No      Auto Deduct:   Yes    No Account: _____________________
Application entered into DCP and routed successfully Entered By: __________________________________________