BVU Residential Loan Program

1. LOAN PURPOSE -

Heat Pump
Home Insulation & Weatherization
Insulated Replacement, Windows/Doors/Garage Doors
Water Heater
Electric Service Upgrades
Exterior Main Water Line Replacement
Exterior Main Sewer Line Replacement
Other:

2. APPLICANT -

Full Name

SS#

DL#/State

E-mail Address

DOB

Home phone#

Work phone#

Cell phone#

Street Address

City

State

Zip

How long at this address?
Yrs

Mos

Own
Rent
Other:

Mailing Address (if different than street address)

City

State

Zip

Previous Address (if current address is less than 3 years)

City

State

Zip

Name/Address of nearest relative not living with you

Telephone #

Relationship

Your Present Employer

Position/Occupation

Employer’s Address

Length of Employment
Yrs

Mos

Gross Monthly Salary

Other Monthly Income

Previous Employer

Previous Employer’s Address (if less than 2 years)

Position/Occupation

Length of Employment
Yrs

Mos

Company Holding Homeowner Insurance Policy

Address

Policy #

3. CO-APPLICANT - (If Co-Applicant other than spouse, complete a seperate application)

Full Name

SS#

DL#/State

DOB

Daytime Phone#

Street Address

City

State

Zip

How long at this address?
Yrs

Mos

Your Present Employer

Position/Occupation

Employer’s Address

Previous Employer

Previous Employer’s Address (if less than 2 years)

Length of Employment
Yrs

Mos

Gross Monthly Salary

Other Monthly Income

4. YOUR FINANCIAL RECORD-
Loans held by financial institutions or individuals as liens against the real property used as collateral for this loan request:

Lender

Outstanding Balance

Lender

Outstanding Balance

I represent and warrant that all of the above statements are true and complete at the date shown below. I agree that this application shall remain Bristol Virginia Utilities’ property. I authorize Bristol Virginia Utilities to make any credit inquiries deemed necessary for the consideration of this loan request with respect to collection of any credit extended in reliance on this application. I authorize any person, governmental or consumer reporting agency to provide information deemed necessary by Bristol Virginia Utilities to process this application. I hereby waive any rights under The Privacy Act of 1974 and authorize any governmental agency to release to Bristol Virginia Utilities my current home and office addresses and telephone numbers. Bristol Virginia Utilities may exchange credit experience on this account with other creditors and consumer reporting agencies.

Signature of Applicant (Full Legal Name)

Date

Signature of Co-Applicant (Full Legal Name)

Date

Completed paper applications should be faxed to (276) 821-6218 or mailed to Bristol Virginia Utilities, P.O. Box 8100, Bristol, VA 24203-8100. attn: Residential Loan Program. If you have questions regarding the Bristol Virginia Utilities Residential Loan Program application, please call (276) 669-4112.