IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNTWhy are we asking for this information? 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 other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents.
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 any information provided to or otherwise collected by PATF may be provided to one or more lenders (each, a “Lender”) in connection with my/our request for financing. I/We authorize PATF to share any and all information with any Lender, and also authorize such Lender to share any and all information regarding me/us, any loan application and any loan (including, without limitation, loan status) referred to such Lender by PATF with PATF and its representatives.
I/We acknowledge and agree that each Lender, its agents, successors and assigns are third-party beneficiaries having the right to enforce the authorizations and certifications contained within this Application, and to exercise any rights and remedies to which they may be entitled at law or in equity./p>
As part of your application for an extension of credit (“loan”) through Pennsylvania Assistive Technology Foundation (PATF), an approved PATF Lender requests your authorization to pull your credit report, including, but not limited to, your personal credit profile and other information on file at one or more consumer reporting agencies (“credit report”). You understand you are providing “written instructions” to the approved PATF Lender under the Fair Credit Reporting Act which authorizes the Lender to procure your credit report from one or more consumer reporting agencies. You authorize the Lender to verify information in your application and agree that the Lender may contact third parties to verify such information. The Lender may use your credit report(s) to authenticate your identity, to make credit decisions, and for related purposes.
PATF Does not reimburse for items already purchased.
(YOU MUST attach quote with detailed information about the product, cost and name of vendor/seller.)
(Check all that apply)
I/We understand that this is a request for funds that I/We will need to repay. I/We authorize Pennsylvania Assistive Technology Foundation (PATF) to review all information provided and seek additional information from third parties required to verify the contents of this application. All information is true and correct and is provided to obtain the loan I/we am/are seeking. Any misrepresentation on any part of this application could result in rejection of this application or termination of the loan.
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.
I/We further understand that issuance of a loan does not imply any type of warranty by PATF or any other lender regarding the suitability, condition, merchantability or safety of the device or equipment that I/we purchase with the loan. I/We understand that I/we alone are responsible for selecting the devices or equipment to be financed. Therefore, I/WE CAN MAKE NO CLAIMS AGAINST PATF OR ANY LENDER OR ANY OF THEIR AGENTS, AND I/WE EACH HEREBY RELEASE PATF AND ANY OTHER LENDER, AND ALL OF THEIR RESPECTIVE AGENTS, FROM AND AGAINST ALL LIABILITY, FOR DEFECTS IN ANY DEVICE OR EQUIPMENT OR ANY ACCIDENT OR INJURY RESULTING FROM ITS USE.
I/We hereby also authorize PATF and any lender to whom PATF may refer this application to disclose to PATF any information about any of us that the lender obtains or compiles that may be relevant to decisions PATF may make with respect to the application.
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.