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UNIFORM RESIDENTIAL LOAN APPLICATION
Welcome to Mid Penn Bank On-Line.  This loan application is intended for current customers or those moving to our geographic area who will be banking with us. 

Our primary service area includes the following counties of Pennsylvania:  Dauphin, Cumberland, Schuylkill and Northumberland.

Our secondary service area includes portions of the following counties of Pennsylvania:  Perry, Juniata, Snyder, York, Lancaster, Lebanon and Adams County.

We are committed to providing you with the best customer service possible which is why we must limit our loan service area.  You will be required to identify yourself as a current customer or as residing in one of the above counties on the loan application for your application to be accepted.  We apologize, but if you do not reside in one of these counties or if you are not a current customer, your application will not be able to be submitted to the bank on-line.  If you should need further assistance with a loan, please e-mail us at mpbank@epix.net.

This application is designed to be completed by the borrower(s) with the lender's assistance. For your convenience, we are providing this application on-line so that the bank can acquire as much information as possible to expedite your mortgage application process before you visit the bank to complete any areas of the application where you need assistance. By mailing this application to the bank, you are authorizing the bank to complete a credit bureau request prior to the completion of the entire application.

Applicants should complete this form as a "Borrower" or Co-Borrower," as applicable. Co-Borrower information must also be provided (and the appropriate box checked) 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 qualification, but his or her liabilities must be considered because the borrower resides in a community property state, the security 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.

Upon receipt of your electronically submitted application, Mid Penn Bank will mail you a copy of the required disclosures within three business days of the date of receipt of your un-signed application. Upon approval of your application, you will be required to sign the loan application at one of our office locations which is convenient to you. Applicants must be 18 years of age or older to apply.



IMPORTANT INFORMATION ABOUT
PROCEDURES FOR OPENING A NEW ACCOUNT

 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, we will ask for your name, address, date of birth and driver's license or other identifying documents.

I. TYPE OF MORTGAGE AND TERMS OF LOAN
Mortgage  Applied for:
VA    FHA    Conventional    FmHA    Other: 
Agency Case  Number
  		Lender Case  Number
 Amount
$ 		Interest  Rate
 No. of  Months
Amortization  Type:
Fixed Rate    GPM    Other (explain):    ARM (type): 
II. PROPERTY INFORMATION AND PURPOSE OF LOAN
Subject  Property Address (street, city, state, & zip code) 
  		No. of  Units
  
Legal  Description of Subject Property (attach description if necessary)
 
Year  Built
   
Purpose  of Loan Purchase
Refinance		 Construction
Construction-Permanent
Other (explain):  
Property will  be:
Primary Residence
Secondary Residence
Investment
Complete  these two lines if construction or construction-permanent  loan.
Year Lot  Acquired:
 Original Cost
$ 		Amount Existing Liens
$
(a) Present Value of Lot
$ 		(b) Cost of Improvements
$ 		Total (a + b)
$
Complete  these two lines if this is a refinance loan.
Year Acquired
  		Original Cost
$ 		Amount Existing Liens
$
Purpose of Refinance
 		 Describe Improvements
made    to be made
Cost: $
Title will be held in what Name(s)
 Manner in which Title will be held
 Estate will be held in:
Fee Simple
Leasehold
(show expiration date)
 
Source of Down Payment, Settlement Charges and/or Subordinate Financing (explain)
III. BORROWER INFORMATION
Borrower
Borrower's Name (include Jr. or Sr. if applicable)
 
Social Security Number
  		Home Phone  (incl. area code)
 		 Birthdate
 		 Yrs. School
 

Complete the Marital Status section ONLY if applying for joint or secured credit.
Marital Status:
 Married
 Separated
 Unmarried (include single, divorced, widowed)

 Current Mid Penn Bank Customer?
Yes No		 Dependents (not listed by  Co-Borrower)
no.        ages

Driver's License Number

DL State

Driver's License Issue Date

Driver's License Expiration Date
Present Address (street, city, state, zip code)     Own    Rent    Yrs.
 
County  
E-mail address
If  residing at present address for less than two years, complete the following:
Former Address (street, city, state, zip code)      Own    Rent    Yrs.
 
Former Address (street, city, state, zip code)      Own    Rent    Yrs.
 
Co-Borrower
Co-Borrower's Name (include Jr. or Sr. if applicable)
Social Security Number
 Home Phone  (incl. area code)
 		 Birthdate
 		 Yrs. School
 
Complete the Marital Status section ONLY if applying for joint or secured credit.
Marital Status:
Married
Separated
Unmarried (include single, divorced, widowed)		 Current Mid Penn Bank Customer Dependents (not listed by  Co-Borrower)
no.        ages

Driver's License Number

DL State

Driver's License Issue Date

Driver's License Expiration Date
Present Address (street, city, state, zip  code)     Own    Rent    Yrs.
E-mail address:
If  residing at present address for less than two years, complete the  following:
Former Address (street, city, state, zip  code)     Own    Rent    Yrs.
Former Address (street, city, state, zip  code)     Own    Rent    Yrs.
IV. EMPLOYMENT INFORMATION
Borrower
Name & Address of Employer
Self Employed
 Yrs. on this job
 
Yrs. employed in this line of work/profession
 
Position/Title/Type of Business
 Business Phone (incl. area code)
 
If  employed in current position for less than two years or if currently  employed in more than one position, complete the  following:
Name & Address of Employer
Self Employed
  		Dates (from-to)
 
Monthly Income
$
Position/Title/Type of Business
 Business Phone (incl. area code)
Name & Address of Employer
Self Employed
  		Dates (from-to)
 
Monthly Income
$
Position/Title/Type of Business
 		 Business Phone (incl. area code)
Co-Borrower
Name & Address of Employer
Self Employed
  		Yrs. on this job
 
Yrs. employed in this line of work/profession
 
Position/Title/Type of Business
 		 Business Phone (incl. area code)
 
If  employed in current position for less than two years or if currently  employed in more than one position, complete the  following:
Name & Address of Employer
Self Employed
  		Dates (from-to)
 
Monthly Income
$
Position/Title/Type of Business
 		 Business Phone (incl. area code)
Name & Address of Employer
Self Employed
  		Dates (from-to)
 
Monthly Income
$
Position/Title/Type of Business
 Business Phone (incl. area code)
V. MONTHLY INCOME AND COMBINED HOUSING EXPENSE INFORMATION
Gross Monthly Income
Borrower
Co-Borrower
Total
Base Empl. Income* $ $ $
Overtime
Bonuses
Commissions
Dividends/Interest
Net Rental Income
OTHER (before completing, see the notice in "describe other income," below)
Total $ $ $

Combined Monthly Housing Expense
Present
Proposed
Rent $
First Mortgage
(P & I)		 $
Other Financing (P & I)
Hazard Insurance
Real Estate Taxes
Mortgage Insurance
Homeowner Assn. Dues
Other:
Total $ $
Self Employed  Borrower(s) may be required to provide additional documentation such as  tax returns and financial statements.
Describe  Other Income


Notice: Alimony, child support, or separate  maintenance income need not be revealed if the Borrower (B) or Co-Borrower  (C) does not choose to have it considered for repaying this loan.

B C Monthly  Amount
$
$
$
VI. ASSETS AND LIABILITIES
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.

Completed   Jointly   Not Jointly

ASSETS

Description

Cash or  Market Value
Cash deposit toward  purchase held by:
$
List  checking and savings accounts below
Name and  address of Bank, S & L, or Credit  Union
Acct. No. $
Name and  address of Bank, S & L, or Credit  Union
Acct. No. $
Name and  address of Bank, S & L, or Credit  Union
Acct. No. $
Name and  address of Bank, S & L, or Credit  Union
Acct. No. $
Stocks & Bonds  (Company name/number & description)
 $
Life insurance net cash  value
 
Face amount: $ 		$
Subtotal Liquid  Assets $
Real estate owned (enter  market value from schedule of real estate owned) $
Vested interest in retirement fund $
Net worth of business(es)  owned (attach financial statement) $
Automobiles owned (make  and year)
 $
Other Assets  (itemize)
 $
Total Assets  a. $
Liabilities  and Pledged Assets. 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 a continuation sheet, if necessary. Indicate by (*) those  liabilities which will be satisfied upon sale of real estate owned or upon  refinancing of the subject property.
LIABILITIES
Monthly  Payt. &
Mos. Left to Pay
Unpaid  Balance
Name and address of Company
 $ Payt.
Mos. 		$
Acct. No.
Name and address of Company
 $ Payt.
Mos. 		$
Acct. No.
Name and address of Company
 $ Payt.
Mos 		$
Acct. No.
Name and address of Company
 $ Payt.
Mos 		$
Acct. No.
Name and address of Company
 $ Payt.
Mos 		$
Acct. No.
Name and address of Company
 $ Payt.
Mos 		$
Acct. No.
Name and address of Company
 $ Payt.
Mos 		$
Acct. No.
Alimony/Child Support/Separate Maintenance Payments Owed to:
 		 $  
Job Related Expense  (child care, union dues, etc.):
 $  
Total Monthly Payments $  
Total  Liabilities b. $
Net Worth (a minus b)
 $
VII. DETAILS OF TRANSACTION
a. Purchase price $
b. Alterations, improvements, repairs  
c. Land (if acquired separately)  
d. Refinance (incl. debts to be paid off)  
e. Estimated prepaid items  
f. Estimated closing costs  
g. PMI, MIP, Funding Fee  
h. Discount (if Borrower will pay)  
i. Total costs (add items a through h)  
j. Subordinate financing  
k. Borrower's closing costs paid by Seller  
l. Other Credits  (explain)
m. Loan amount (exclude  PMI, MIP, Funding Fee financed)  
n. PMI, MIP, Funding Fee financed  
o. Loan amount (add m & n)  
p. Cash from/to Borrower  (subtract j, k, l & o from i)  
VIII. DECLARATIONS
If you  answer "yes" to any questions a through i, please use a continuation sheet  for explanation.
Borrower
Co-Borrower
a. Are there any outstanding judgements against you?
Yes
No
Yes
No
b. Have you been declared bankrupt within the past 7 years?
Yes
No
Yes
No
c. Have you had property foreclosed upon or given title or deed in lieu thereof in the last 7 years?
Yes
No
Yes
No
d. Are you a party to a lawsuit?
Yes
No
Yes
No
e. Have you directly or  indirectly been obligated on any loan which resulted in foreclosure,  transfer of title in lieu of foreclosure, or judgement? (This would  include such loans as home mortgage loans, SBA loans, home improvement  loans, educational loans, manufactured (mobile) home loans, any mortgage,  financial obligation, bond, or loan guarantee. If "Yes," provide details,  including date, name and address of Lender, FHA or VA case number, if any, and reasons for the action.)
Yes