Read about accessing Assistive Technology through Community HealthChoices
Fields marked with a * are required.
Alimony, Child Support, Separate Maintenance Payments: You are not required to disclose income from alimony, child support, or separate maintenance payments. However, if you are relying on income as a basis for repayment of this obligation, please complete the information below. Documentation verifying income will be required.
(Include installment loans, credit cards, rent, mortgages, etc.) Use separate sheet if necessary.
I/We understand and agree that the information in this application and otherwise collected by PATF may, depending upon the amount and type of credit requested, be provided to one or more Lenders (each, a "Lender") in connection with my/our request for financing.
Certification: I/We certify that the information provided in this application is true and correct as of the date set forth opposite my/our signature on this application and acknowledge my/our understanding that any intentional or negligent misrepresentation of the information contained in this application may result in civil liability and/or criminal penalties including, but not limited to, fine or imprisonment or both under the provisions of Title 18, United States Code, Section 1001 et seq., and liability for monetary damages to PATF, any other lender, its agents, successors, assigns, insurers, and any other person who may suffer any loss due to reliance upon any misrepresentation I/we made in this application or in any other manner.
PATF Does not reimburse for items already purchased.
(YOU MUST attach quote with detailed information about the product, cost and name of vendor/seller UNLESS you are applying for a PRE-APPROVAL).
(Check all that apply)
Your privacy is important to us, and maintaining your trust and confidence is one of our highest priorities.
We respect your right to keep your personal information confidential and understand your desire to avoid
will have a better understanding of what we do with the information you provide us and how we strive to
keep it private and secure.
This notice explains how we collect, handle and disclose personal information about you.
Information We Collect:
We collect non-public personal information about you from the following sources:
Information We May Disclose:
We do not disclose non-public personal information about our applicants or borrowers or former applicants
or borrowers to anyone, except to our partner banks, the credit bureaus and as required by law.
Confidentiality and Security of Non-Public Personal Information
Confidentiality and security of your non-public personal information is of paramount importance to us. We
maintain physical, electronic and procedural safeguards in compliance with all applicable laws and
regulations to guard your non-public personal information from unauthorized access, alteration and
destruction. We restrict access to your non-public personal information to those employees and other
parties who must use the information to provide services to you.
INFORMATION FOR GOVERNMENT MONITORING PURPOSES (APPLICANT AND CO-APPLICANT)The following information is requested by the federal government for certain types of loans related to a dwelling in order to monitor the lender’s compliance with equal credit opportunity, fair housing, and home mortgage disclosure laws. You are not required to furnish this information, but are encouraged to do so. You may select one or more designations for "Race". The law provides that a lender may not discriminate on the basis of this information, or on whether you choose to furnish it. However, if you choose not to furnish the information and you have made the application in person, under federal regulations the lender is required to note ethnicity, race, and sex on the basis of visual observation or surname. If you do not wish to furnish this information, please check below.