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WisLoan Application : office use only Application # Date Received
Loan Amount:___________Applicant
Legal Name (Mr/Mrs/Ms): First Middle Last Jr/Sr
Married _____ Unmarried ______ Separated ______
Soc Security Number _________-__________-__________ DOB______/_____/___________(include copy with application) mm/dd/yyyy
Street Address: ___
City ________________________ State WI Zip Code __________ County __________________
How long have you lived at this address: Years ___________ Months ________________
P revious Address (If less than 2 years at current address)
Street Address ___________________________________ City __________________________
State ____ Zip Code _________ How long did you live at this address: Years _____ Months _____
Government ID with picture ID Form:________________ Issuer: _________________________
#___________________ Date of Issuance: ________________ Exp. date________________(include copy with application)
Number of people in your household: ______ Ages and relation to you:
Home phone number: _______________________ Cell phone: __________________________
Email: _____________________________________ Work phone: _________________________
Mailing Address (if different than street address):
Best number to contact you at: Home/Cell/Email/Work Best time: ________________________
Name of nearest relative or other party not living with you: (Reference will be contacted)
Name: ________________________________ Relationship:_______________________________
Address: _______________________________________ Phone:___________________________
1Updated 04/19/2016
Applicant Income
Note: Send documents for proof of income, payment statements and bank statements. They are required and to be initialed by staff to ensure receipt. Follow Wisloan checklist for detailed income breakdown.
Type of Income Monthly Gross Income Initials of staff
Wages (gross) 1st job $ Copy
Wages (gross) 2nd job $__________________ Copy
SSDI $__________________ Copy _____
Dependent SSDI $__________________ Copy _____
Federal SSI $__________________ Copy _____
State SSI $_________________ Copy _____
Caretakers Supplement $_________________ Copy _____
Soc Sec $_________________ Copy _____
Other
________________ $__________________ Copy _____
________________ $_________________ Copy _____
Total $__________________
Do you receive Foodshare: Yes _____ No _____ Amount: $_________
Is any income likely to be reduced before the credit request is paid off? No _____ Yes _____
Explain: ___________________________________________________________________
_______________________________________________________________________
Employer (1st job): ____________________________ Phone: _________________________
Position or Title: ________________________________ Employed: Years _____ Months _____ Employer (2nd job): Phone: _________________________
Position or Title: ________________________________ Employed: Years _____ Months _____
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Applicant Monthly Debt
Housing Cost (include only APPLICANT’S responsibility)
_____ Rent _____ Own a home _____ Own a mobile home
If You Rent
Monthly rent you pay: _________
Is this subsidized housing: No _____ Yes _____
Name of Landlord________________________ Phone: _________________________
If You Own a Home
Monthly mortgage you pay: $_________
Who is your mortgage with? _____________________ (Include copy of mortgage statement)
Does mortgage payment include property tax: No _____ Yes _____
If answer is no, what is the monthly property tax: $
Does mortgage payment include homeowners Insurance: No _____ Yes _____
If answer is no, what is the monthly homeowners insurance: $
If You Own a Mobile Home
Monthly mortgage you pay: $ _________
Monthly lot rent: $ _________
Additional monthly fees: $ _________
Notes:
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Applicant Monthly Expenses
Type of Expense Monthly Expense Amt Initials of staff
Utilities $ Copy _____
Renters Insurance $__________________ Copy _____
Credit Card payments $__________________ Copy
Auto Loan $__________________ Copy _____
Vehicle Insurance $__________________ Copy _____
Life Insurance $__________________ Copy _____
Cable/Internet $__________________ Copy _____
Child Care $__________________ Copy _____
Phone/Cell Phone $_________________ Copy _____
Personal Loans $__________________ Copy _____
Condo Fees $_________________ Copy _____
Alarm System $_________________ Copy _____
Bus Equipment Lease $_________________ Copy _____
Bus Line of credit $_________________ Copy _____
Total $__________________
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Applicant Credit History
Describe your credit history: Good _____ Fair _____ Needs work _____ Don’t know _____
Have you filed for bankruptcy in the last 10 years: No _____ Yes _____
Chapter 7 (elimination of debt): _____ Date finalized: _____________
Include a list of all creditors included in the bankruptcy.
Chapter 13 (reorganization of debt): _____ Date started: _______________ If repayment of Chapter 13 is active, include the payment schedule that lists the creditors.
Explain what caused any credit problems. Explain how you have addressed those issues. If you filed bankruptcy in last 10 years, give detailed reasons for the bankruptcy.
If you have debt you have not paid, explain why and how you will repay this loan if you are approved.
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Co – Applicant
Legal Name (Mr/Mrs/Ms): First Middle Last Jr/Sr
Married _____ Unmarried ______ Separated ______
Soc Security Number _________-__________-__________ DOB______/_____/___________(include copy with application) mm/dd/yyyy
Street Address:
City ________________________ State WI Zip Code __________ County __________________
How long have you lived at this address: Years ___________ Months ________________
P revious Address (If less than 2 years at current address)
Street Address ___________________________________ City __________________________
State ____ Zip Code _________ How long did you live at this address: Years _____ Months _____
Government ID with picture ID Form: ________________ Issuer: _________________________
#___________________ Date of Issuance: ________________ Exp. Date: ________________(include copy with application)
Number of people in your household: ______ Ages and relation to you:
Home phone number: _______________________ Cell phone: __________________________
Email: _____________________________________ Work phone: _________________________
Mailing Address (if different than street address):
Best number to contact you at: Home/Cell/Email/Work Best time: ________________________
Name of nearest relative or other party not living with you: (Reference will be contacted)
Name: ________________________________ Relationship:_______________________________
Address: _______________________________________ Phone:___________________________
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Co - Applicant Income
Note: Send documents for proof of income, payment statements and bank statements. They are required and to be initialed by staff to ensure receipt. Follow Wisloan checklist for detailed income breakdown.
Type of Income Monthly Gross Income Initials of staff
Wages (gross) 1st job $ Copy
Wages (gross) 2nd job $__________________ Copy
SSDI $__________________ Copy _____
Dependent SSDI $__________________ Copy _____
Federal SSI $__________________ Copy _____
State SSI $_________________ Copy _____
Caretakers Supplement $_________________ Copy _____
Soc Sec $_________________ Copy _____
Other
________________ $__________________ Copy _____
________________ $_________________ Copy _____
Total $__________________
Do you receive Foodshare: Yes _____ No _____ Amount: $_________
Is any income likely to be reduced before the credit request is paid off? No _____ Yes _____
Explain: ___________________________________________________________________
_______________________________________________________________________
Employer (1st job): ____________________________ Phone: _________________________
Position or Title: ________________________________ Employed: Years _____ Months _____ Employer (2nd job): Phone: _________________________
Position or Title: ________________________________ Employed: Years _____ Months _____
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Co - Applicant Monthly Debt
Housing Cost (include only CO-APPLICANT’S responsibility)
_____ Rent _____ Own a home _____ Own a mobile home
If You Rent
Monthly rent you pay: _________
Is this subsidized housing: No _____ Yes _____
Name of Landlord________________________ Phone: _________________________
If You Own a Home
Monthly mortgage you pay: $_________
Who is your mortgage with? _____________________ (Include copy of mortgage statement)
Does mortgage payment include property tax: No _____ Yes _____
If answer is no, what is the monthly property tax: $
Does mortgage payment include homeowners Insurance: No _____ Yes _____
If answer is no, what is the monthly homeowners insurance: $
If You Own a Mobile Home
Monthly mortgage you pay: $ _________
Monthly lot rent: $ _________
Additional monthly fees: $ _________
Notes:
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Co- Applicant Monthly Expenses
Does co-applicant live with applicant yes___ no ___
Type of Expense Monthly Expense Amt Initials of staff
Utilities $ Copy _____
Renters Insurance $__________________ Copy _____
Credit Card payments $__________________ Copy
Auto Loan $__________________ Copy _____
Vehicle Insurance $__________________ Copy _____
Life Insurance $__________________ Copy _____
Cable/Internet $__________________ Copy _____
Child Care $__________________ Copy _____
Phone/Cell Phone $_________________ Copy _____
Personal Loans $__________________ Copy _____
Condo Fees $_________________ Copy _____
Alarm System $_________________ Copy _____
Bus Equipment Lease $_________________ Copy _____
Bus Line of credit $_________________ Copy _____
Total $__________________
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Co – Applicant Credit History
Describe your credit history: Good _____ Fair _____ Needs work _____ Don’t know _____
Have you filed for bankruptcy in the last 10 years: No _____ Yes _____
Chapter 7 (elimination of debt): _____ Date finalized: _____________
Include a list of all creditors included in the bankruptcy.
Chapter 13 (reorganization of debt): _____ Date started: _______________ If repayment of Chapter 13 is active, include the payment schedule that lists the creditors.
Explain what caused any credit problems. Explain how you have addressed those issues. If you filed bankruptcy in last 10 years, give detailed reasons for the bankruptcy.
If you have debt you have not paid, explain why and how you will repay this loan if you are approved.
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Assistive Technology Consumer (person with a disability)
Name: ________________________________________________________________________
Date of Birth: ______________ Age: __________
Relationship to Applicant/Co Applicant: ____________________________________________
If address is different than the applicant or co applicant, list the AT Consumer’s address:
______________________________________________________________________________
Describe disability (date of onset, primary functional limitations due to the disability):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Assistive Technology Device or Service (If request is for a Modified Vehicle include copy of vehicle insurance or insurance quote from agent)(If request is a Home Modification skip this page and complete the separate sheet for Home Modifications)
What is the AT you want to purchase with the loan: (provide quotes, invoices, ads or specification sheets)
Explain how the equipment will assist you with: independence / employment / education
How are you currently performing tasks without the requested equipment/service:
How did you decide on the Assistive Technology/Service:
Tried device at ILC _____ Tried device at retailer/distributor _____
Recommended by health care provider _____ Owned similar device before _____
Other _____ Please explain:
Are you currently an open consumer with the ILC for other services: No _____ Yes _____
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Additional Funding
Do you currently receive services from:
DVR ____ Family Care _____ IRIS _____ LTC (COP/CIP) _____ VA _____
Medicaid _____ Medicare _____ Other
Have you applied for funding from any of the above entities or other organizations for
AT/Service/ Home Modification and been denied? No _____ Yes _____
If yes, list the entities that denied your request:
Are you pursuing any other funding sources to assist with your purchase: No _____ Yes _____
If yes, complete an Authorization to Release Information for each funder and complete information below.
AT requested to be covered by the other funding source:
Name of Entity: _________________________ Contact Person:
Phone Number: Email:
Amount they have agreed to pay $ ____________
Request is being reviewed, I expect a decision by (date):
(If request has been made to more than one entity, please provide additional information in the note section at the end of the application)
Loan Request (Loan request amount, term and monthly payment must be completed)
Total amount of loan request: $
Term: _________ Monthly payment $__________ Interest rate 6.5%
Monthly payment you feel you can afford: $
I acknowledge that direct withdrawal for the monthly payment is required _________ Initial
Signed ACH form received Voided check received
Can you put any money towards the purchase: No _____ Yes _____ How Much?
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Agreement/ Authorization
I certify, under penalty of law that the information given in this application is correct to the best of my knowledge. I understand if any information on the application is found to be false, my application may be rejected or my loan may be terminated. I understand this is a request for funds that I must repay. I authorize the WisLoan Coordinator and staff at the Independent Living Center to share information as it relates to the request for a loan through the WisLoan Program. I authorize the WisLoan Program through IndependenceFirst to obtain a copy of my credit report. I agree to waive the right to a decision in 30 or fewer days for a loan guarantee from WisLoan.
I understand that I am responsible for selecting the device, service or home modification to be financed. The issuance of a loan does not imply any type of warranty by WisLoan/IndependenceFirst, the Independent Living Center that assisted with the application process or any lender regarding the suitability, condition or safety of the device, service or home modification I purchase with the loan. Therefore, I can make no claims against the WisLoan Program, IndependenceFirst, the Independent Living Center that serves your area, any lender or any of their agents, and I release WisLoan, IndependenceFirst, the Independent Living Center, lender or any of their agents from and against all liability, for defects in any device, service or home modification from any accident or injury resulting from its use.
I authorize WisLoan to share all financial, credit and other pertinent information with BMO Harris Bank for loan maintenance purposes. I authorize BMO Harris Bank to share all loan information with the WisLoan Program for maintenance purposes if I receive a loan through the Program.
I acknowledge and understand that if I am approved for a loan, I will have to sign separate loan documents. Those documents will govern the terms and conditions of the loan. I understand that if I fail to repay the loan as outlined in the loan agreement, IndependenceFirst will be required to pay the balance of the loan. In such event IndependenceFirst will take an assignment of the loan and IndependenceFirst will have all of the remedies available under the loan documents, including, but not limited to the ability to initiate legal action to collect on the debt or any secured collateral. If I am late with a payment I understand I will be contacted to discuss the situation. I agree to notify WisLoan in writing of any change of name, address and employment. I agree to be contacted in the future by the WisLoan Program for follow-up interviews.
Signature of applicant or guardian Date
Signature of co-applicant or guardian Date
Signature of co-applicant or guardian Date
___________________ Print name of ILC staff assisting with application Date
Email for ILC Staff Phone Number _____________________
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Agreement/ Authorization – Applicant Copy
I certify, under penalty of law that the information given in this application is correct to the best of my knowledge. I understand if any information on the application is found to be false, my application may be rejected or my loan may be terminated. I understand this is a request for funds that I must repay. I authorize the WisLoan Coordinator and staff at the Independent Living Center to share information as it relates to the request for a loan through the WisLoan Program. I authorize the WisLoan Program through IndependenceFirst to obtain a copy of my credit report. I agree to waive the right to a decision in 30 or fewer days for a loan guarantee from WisLoan.
I understand that I am responsible for selecting the device, service or home modification to be financed. The issuance of a loan does not imply any type of warranty by WisLoan/IndependenceFirst, the Independent Living Center that assisted with the application process or any lender regarding the suitability, condition or safety of the device, service or home modification I purchase with the loan. Therefore, I can make no claims against the WisLoan Program, IndependenceFirst, the Independent Living Center that serves your area, any lender or any of their agents, and I release WisLoan, IndependenceFirst, the Independent Living Center, lender or any of their agents from and against all liability, for defects in any device, service or home modification from any accident or injury resulting from its use.
I authorize WisLoan to share all financial, credit and other pertinent information with BMO Harris Bank for loan maintenance purposes. I authorize BMO Harris Bank to share all loan information with the WisLoan Program for maintenance purposes if I receive a loan through the Program.
I acknowledge and understand that if I am approved for a loan, I will have to sign separate loan documents. Those documents will govern the terms and conditions of the loan. I understand that if I fail to repay the loan as outlined in the loan agreement, IndependenceFirst will be required to pay the balance of the loan. In such event IndependenceFirst will take an assignment of the loan and IndependenceFirst will have all of the remedies available under the loan documents, including, but not limited to the ability to initiate legal action to collect on the debt or any secured collateral. If I am late with a payment I understand I will be contacted to discuss the situation. I agree to notify WisLoan in writing of any change of name, address and employment. I agree to be contacted in the future by the WisLoan Program for follow-up interviews.
Signature of applicant or guardian Date
Signature of co-applicant or guardian Date
Signature of co-applicant or guardian Date
___________________ Print name of ILC staff assisting with application Date
Email for ILC Staff Phone Number _____________________
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