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Co Maker Form

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CO-MAKER’S/GUARANTOR’S STATEMENT

This statement should be completed only if another person in addition to the applicant will be obligated to repay the loan.
Name of Co-Maker/Guarantor
Address Social Security Number
Relation to Applicant (if any) Name of your Credit Union Acct. No.
Home Phone Cell Phone Best Contact Method

I am indebted to the following creditors (List all debts such as Complete the following only if you reside in a community
doctor bills, real estate, automobile, repairs, furniture, property state (Arizona, California, Idaho, Louisiana, New Mexico,
installments, loans, etc. Attach additional sheet if necessary): Nevada, Texas or Washington):
To Whom Owed (Name & Original Monthly Balance Married:  Separated:  Unmarried: 
Address) Amount Payment
Auto Owned, Make
Year Ser. or Mtr. No.
2nd Auto Owned, Make
Year Ser. or Mtr. No.
Drivers Licenses Number State

Real Estate Owned at reasonable market value $


Location
I hereby affirm and represent that my total indebtedness and Name of Landlord Monthly Rent $
liabilities on this date are listed above and do not exceed List all addresses for past five years:
$ .

Number of dependents (Exclude self)


Are you liable for alimony, child support or separate maintenance
payments?  No  Yes $ /Month
Parents or nearest relatives
Employer Name Relationship
Address Address
Date Employed Date of Birth Have you any Judgments, Garnishments, or Legal Proceedings
Position against you? If “Yes” explain
Clock or Payroll No. Office Phone & Ext.
Weekly/Monthly Salary $ Have you ever been through Bankruptcy? Year
Previous Employer Are you a co-maker/guarantor on any other loans?
Length of Service Amount $
If so, for whom
Other Personal Income (do NOT include alimony, child support or
separate maintenance payments) $ List Credit References: (If renewal, add new references)
Source Name Address
You need not disclose the following sources of income; but if you Name Address
want the credit union to consider such income in connection with Name Address
this statement, please complete the following: Bank References – Checking and Savings
Alimony $ Child Support $
Separate Maintenance Payments $
Additional Information
Complete the following only if you have chosen to disclose
alimony, child support, or separate maintenance income:
Person Liable
Address
Employer
I hereby certify that all statements made, are true and complete
Address and submitted for the purpose of obtaining credit. I have no
Date employed Position other debts. The credit union is authorized to check my credit
Weekly/Monthly Salary $ and employment history and to answer questions about its credit
How long have alimony, child support or separate maintenance experience with me.
payments been made? Are all payments up to
date?  No  Yes
Signature Date

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