Personal Details
Title Mr Mrs Ms Miss Other (please specify)
Surname
Previous Name(s)
Forename(s) Middle Name(s)
Date of Birth Age National Insurance No.
Home Address
Post Code Area of Town i.e. West Marsh
Time at Current address
If less than 3 years please provide details of previous addresses in the past 5 years below.
Telephone No. Landline/Mobile
A phone number
must be included
Residential Status Owner Mortgaged Property Tenant Housing AssociationTenant with Private Landlord With Family / Friends No Fixed Abode No. In Household No. of Adults No. of Children under 5 No. of Children over 5
Marital Status Married / Living with Partner Divorced Separated Widowed Single
Email Address Previous Addresses Postcode Time at Address Postcode Time at Address Postcode Time at Address
Are you an current CU member? YES NO Are you a new borrower? YES NO Have you been a CU member? YES NO Membership Number
How did you hear about the Credit Union?
Do you consider yourself to be disabled or have a long term illness? YES NO If so, please give details
Loan Number
...
Loan
Application Form
To be completed in BLOCK CAPITALS and returned to:
Customer Services NELCU Municipal Office Town Hall Square Grimsby North East Lincolnshire DN31 1HU Tel 01472 361990 www.nelcu.org.uk
Employment Details
Employment Status Employed Self Employed Retired Unemployed
Full Time Part Time Incapacity Student Other
Employer’s Name Employer’s
Telephone No. Employer’s address
Post code
Occupation Time with Employer
Do you receive any DWP benefits or HMRC Tax Credits? YES NO
Benefit type How much £ Paid Weekly/
Fortnightly/Monthly
If necessary please continue in Other Information
Credit History Details (previous bad credit history may not necessarily count against you)
Who else do you owe money to? Please list all Loans, Mortgages, Car Finance, HP, Credit/Store Cards,Catalogue, Doorstep/Payday Lenders etc
Start date Name of Bank/Agency/loan/Company Original amount £
Repayment amount £ and term
Outstanding balance £
If necessary please continue in Other Information
Have you ever been declared bankrupt? If Yes please give details : YES NO
Do you have any CCJs against you? (Failure to provide this information will result in
the loan being refused ) YES NO
Date Name of company or person Original amount £
Repayment amount/term £
Outstanding balance £
Brief details of circumstances:
Date Name of company or person Original amount £
Repayment amount/term £
Outstanding balance £
Brief details of circumstances:
Date Name of company or person Original amount £
Repayment amount/term £
Outstanding balance £
Brief details of circumstances:
This is a true and accurate statement of my finances.
Signed: _________________________________
Income & Expenditure Details - Please include all household income & expenditure
INCOME Per Month
Week - M - W Per Month Week - M - W
Salary/wages Applicant £ Universal Credit £
Salary/wages Partner’s £ £
Pension £ £
Child Tax Credit £ £
Working Tax Credit £ £
Child Benefit £ £
Housing Benefit £ £
Council Tax Benefit £ £
Incapacity £
Income support £ Other income (please specify)
ESA £ £
JSA £ £
DLA /PIP £ £
Total (A)
OUTGOINGS Per Month
Week - M - W Per Month Week - M - W
Rent / Mortgage £ Bank Loan £
Council Tax £ Bank Overdrafts £
Electricity / Gas / Heating Oil £ Catalogues £
Water £ Credit / Store Cards £
Telephone / Mobile £ Car Loan £
TV / SKY / Digital incl. Licence £ Hire Purchase £
Broadband / Internet £ Payday Loans £
Housekeeping
(e.g. food, toiletries, nappies, drinks, magazines)
£ Other Loans e.g. doorstep
lenders, moneyline £
Clothing £ Car Insurance £
Smoking £ Breakdown cover £
Pets e.g. food, vet bills &
insurance £ Petrol £
Home Insurance £ Travel & Public Transport £
School & Nursery Costs, incl.
school dinners & uniform £ Life Assurance £
Social Expenses e.g.
memberships, subscriptions £ Pensions £
Other Outgoings(please specify) £ Savings & Investments £ £
Total (B)
£Loan Details
Purpose of loanHow much do you wish to borrow? £
Repayment amount £ Weekly * Fortnightly* Monthly*
Repayments Method Standing Order * Benefits* Payroll Deduction *
Other (Agreed by CU) *
* Tick as appropriate
What date in the month will you make your repayment? (Standing Order/Payroll only)
How would you prefer the loan paid out to you?
BACS Payment Sort Code Bank account no
Prepaid Card Load Cheque Made Out for Cash Cheque Payable to: Name
For Starter Loan Applicants
If this application is successful the Credit Union requires that before receiving the loan at least one type of benefit must be paid through the Credit Union. Loans will be paid out only after the benefit payment is received.
Type of benefit Reference
Please pay the outstanding amount of my benefit into
My nominated Bank account Sort Code Account no My CU savings account
Personal Details of Contact Person (not at the same address)
Title Mr Mrs Ms Miss Other (please specify)
Surname Forename(s) Home Address
Post Code This person’s relationship to you
Home Telephone No. (inc STD)
Mobile Telephone No.
I hereby give North East Lincolnshire Credit Union permission to contact the above person
in the event that the Credit Union lose contact with me
North East Lincolnshire Credit Union Ltd is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Also a member of the Financial Services Compensation Scheme, the Financial
Ombudsman Service and ABCUL. FSA Reg No: 213655 Reg No: 604C Registered Office: Ground Floor, St James house, St James Square Grimsby DN31 1EP
Data Protection Statement
In accordance with the principles of the Data Protection Act 1998, we will use your personal details for the purposes of managing your accounts with the credit union. Your personal details will be treated confidentially and will only be shared with other agencies for the purposes of credit referencing and debt recovery.
We may at times use your details to keep you informed of services available from the credit union. If you wish your details to be used for these marketing purposes, please tick this box.
Partner’s Declaration
If you have declared your partner’s income details as part of your overall income for this loan, your
partner will need to sign below confirming agreement of their information to be used in considering
the loan and its repayment.
Signed
Print Name
Date
Formal Declaration
I declare that the information I have given on this form is, to the best of my knowledge and belief,
accurate and full information. I understand that the provision of false information is fraud and that
the credit union may take appropriate action if I am found to have deliberately provided false or
misleading information.
Signed
Print Name
Date
For Official Use Only
Received by: Date Received:
Documents Received Proof of ID Proof of Address Income Bank Statements N I no Other – please state
Comments:
Decision : Approved / Refused / Referred Reason:
Term of loan _____ Weeks / Months / Years Date member informed:
Authorised by: Print name:
Input to curtains by Date:
North East Lincolnshire Credit Union Ltd is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Also a member of the Financial Services Compensation Scheme, the Financial
Ombudsman Service and ABCUL. FSA Reg No: 213655 Reg No: 604C Registered Office: Ground Floor, St James house, St James Square Grimsby DN31 1EP
