Basile State Bank Originating Co. NMLS# ID: 460576
William J. Johnson Originator NMLS# ID: 710168
Kimberly L. LeBleu Originator NMLS# ID: 710169
Matthew Caleb Andrus Originator NMLS# ID: 143396
To help the government fight the funding of terrorism and
money laundering activities, Federal law requires all financial institutions
to obtain, verify, and record information that identifies each person who
opens an account. What this means for you: When you open an account, or
apply for a loan, we will ask your name, address, date of birth, and other
information that will allow us to identify you. We may also ask to see
your driver's license or other identifying documents.
This application is designed to be completed
by the applicant (s) with the lender's assistance. Please indicate whether you intend to apply for individual or
joint credit. Applicants for joint credit should complete the applicable
co-borrower sections of the application. Co-borrower information must be
provided when the income or assets of a person other than the "Borrower"
(including the Borrower's spouse) will be used as a basis for loan
qualification, or the income or assets of the Borrower's spouse will not be
used as a basis for loan qualification, but his or her liabilities must be
considered because the Borrower resides in a community property state, the
secured property is located in a community property state, or the Borrower is
relying on other property located in a community property state as a basis for
repayment of the loan.
You must be a U. S. Citizen with a U.S. address and Social
Security number to apply online All other applicants should contact us
Purpose of Loan:
If other, please explain:
Notice: Do not enter a P. O. Box unless
you are currently serving in the military.
Notice: Marital status should only be completed if applicant
is applying for joint or secured credit, or if applicant resides in
a community property state, or is relying on property located in such
Notice: Do not enter a P. O. Box unless you are currently serving in
Notice: Marital status should only be completed
if applicant is applying for joint or secured credit, or if applicant
resides in a community property state, or is relying on property located
in such a state.
This Statement and any applicable
supporting schedules may be completed jointly by both married and unmarried
Co-Borrowers if their assets and liabilities are sufficiently joined
so that the Statement can be meaningfully and fairly presented on a
combined basis; otherwise separate Statements and Schedules are required.
If the Co-Borrower section was completed about a spouse, this Statement
and supporting schedules must be completed about that spouse also.
Total Assets a.
List the creditor's name, address and account number for all outstanding
debts, including automobile loans, revolving charge accounts, real estate
loans, alimony, child support, stock pledges, etc. Use continuation
sheet, if necessary.
(If Additional Properties Owned Attach Separate Schedule)
(1) What type of property did you own: principle residence (PR)
second home (SH), or investment property(IP)?
(2) How did you hold title to the home: solely by yourself (S),
jointly with spouse (SP), or jointly with another person (O)?
The following information is requested by the Federal Government for
certain types of loans related to a dwelling in order to monitor the
lender’s compliance with equal credit opportunity, fair housing, and
home mortgage disclosure laws. You are not required to furnish this
information, but are encouraged to do so. The law provides that a lender
may discriminate neither on the basis of this information, nor on
whether you choose to furnish it. If you furnish the information, please
provide both ethnicity and race. For race, you may check more than
one designation. If you do not furnish ethnicity, race, or sex,
under Federal regulations, this lender is required to note the
information on the basis of visual observation or surname. If you
do not wish to furnish the information, please check the box below.
Certification: I/We certify that the information provided in this application
is true and correct as of the date set forth opposite my/our signature(s)
on 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 on this