APPLICANT LOAN REPORT  Word document

What is your disabling condition?

What type of modified transportation do you want to purchase?  Please describe, must provide make, model, mileage, year and price.

Do you have past credit problems (6 months ago or more)?       Yes                 No

      If yes, describe:

Do you have current credit problems (in the last 6 months)?     Yes                 No

      If yes, describe:

What arrangements have you made to pay any past due bills?

Do you have medical insurance; if so, who is your insurer?

What is your current adaptive method?  Do you have any support or assistance in the home, for example: a spouse, family member and or in-home assistance care?

How did you find out about this low interest loan program?

Other comments, if you would like to explain anything else on this guarantee loan request.

APPLICANT LOAN REPORT

What is your disabling condition?

What type of assistive technology do you want to purchase?  Please describe.

Do you have past credit problems (6 months ago or more)?       Yes                   No

      If yes, describe:

Do you have current credit problems (in the last 6 months)?        Yes                   No

      If yes, describe:

What arrangements have you made to pay any past due bills?

Do you have medical insurance; if so, who is your insurer?

What is your current adaptive method?  Do you have any support or assistance in the home, for example: a spouse, family member and or in-home assistance care?

How did you find out about this low interest loan program?

Other comments, if you would like to explain anything else on this guarantee loan request.

APPLICANT LOAN REPORT for MODIFIED TRANSPORTATION

What is your disabling condition?

What type of modified transportation do you want to purchase?  Please describe, must provide make, model, mileage, year and price.

Do you have past credit problems (6 months ago or more)?       Yes                  No

         If yes, describe:

Do you have current credit problems (in the last 6 months)?        Yes                   No

        If yes, describe:

What arrangements have you made to pay any past due bills?

Do you have medical insurance; if so, who is your insurer?

What is your current adaptive method?  Do you have any support or assistance in the home, for example: a spouse, family member and or in-home assistance care?

How did you find out about this low interest loan program?

Other comments, if you would like to explain anything else on this guarantee loan request.

APPLICANT LOAN REPORT

What is your disabling condition?

What type of assistive technology do you want to purchase?  Please describe.

Do you have past credit problems (6 months ago or more)?      Yes                  No

    If yes, describe:

Do you have current credit problems (in the last 6 months)?      Yes                  No

    If yes, describe:

What arrangements have you made to pay any past due bills?

Do you have medical insurance; if so, who is your insurer?

What is your current adaptive method?  Do you have any support or assistance in the home, for example: a spouse, family member and or in-home assistance care?

How did you find out about this low interest loan program?

Other comments, if you would like to explain anything else on this guarantee loan request.