*Indicates a required field
Applicant's Other Income
Income for SSI, retirement, disability, alimony, child support, or other separate maintenance agreement need not be disclosed if you do not wish to have it considered as a basis for undertaking or repaying this debt.
Demographic Information - this section asks about your ethnicity, sex, and race
The purpose of collecting this information is to help ensure that all applicants are treated fairly and that the housing needs of communities and neighborhoods are being fulfilled. For residential mortgage lending, Federal law requires that we ask applicants for their demographic information (ethnicity, race, and sex) in order to monitor our compliance with equal credit opportunity, fair housing, and home mortgage disclosure laws. You are not required to provide this information, but are encouraged to do so. The law provides that we may not discriminate on the basis of this information, or on whether you choose to provide it. However, if you choose not to provide the information and you have made this application in person, Federal regulations require us to note your ethnicity, race, and sex on the basis of visual observation or surname. The law also provides that we may not discriminate on the basis of age or marital status information you provide in this application.
Instructions: You may select one or more designations for "Ethnicity" and one or more designations for "Race." If you do not wish to provide some or all of this information, select the applicable check box.
Sales & Transaction Information:
Manufactured Home Information:
Certify and Sign
I/We certify that the information stated is complete and accurate, and has been furnished by me (us) knowing that you intend to rely on it in considering my (our) application. I (we) understand that you may request a consumer report in connection with this application and for the purpose of updating, renewing or extending further credit, and, if I (we) ask, I (we) will be informed whether or not such a report was requested (and, if so, the name and address of the consumer reporting agency that furnished the report). I (we) agree that this application remains the property of MHD Empire Service Corp. whether or not a loan is granted. I (we) also authorize you to check my (our) employment/income history and to exchange account and credit information about me (us) with anyone you may ask. 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. When you open an account, we will ask for your name, address, date of birth and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying information. It is a crime to intentionally falsify information on this application.