Non Home Loan Consumer Application

Impact Bank is located solely within the State of Kansas, county of Sumner, USA. Our trade area includes Sumner County and under certain circumstances neighboring counties including Sedgwick, Harper, and Cowley. Applications outside our trade area will not be accepted through the Internet.


To help the government fight the funding of terrorism and money laundering activities, the USA Patriot Act 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, physical adress, date of birth, taxpayer identification number and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents. We will let you know if additional information is required.

 * Required Fields
Non Home Loan Consumer Application
Requested Loan Amount:* $.00
Purpose of Loan:*
If Purpose of Loan involves a vehicle, please provide the Year,
Make, Model and Mileage:
Please read following directions before completing this application, and choose the appropriate circle.
Individual Credit Joint Credit
 Check here if you are applying for individual credit. This means you are applying in your own name and are relying on your own income or assets, NOT those of another person as the basis for repayment.

Complete only the applicant information.
 Check here if you are applying for joint credit. This means you are applying for credit with another person and will be relying on both your and their income or assets as the basis for repayment.

We intend to apply for joint credit.

Applicant:  (please initial)
Co-Applicant:  (please initial)
(Required if Joint Credit selected)

Complete both the applicant information and, the co-applicant information.
Applicant Information
Are you an existing customer of Impact Bank? Yes  No
First Name:*
Middle Initial:
Last Name:*
Date of Birth:*  /   / 
Mother's Maiden Name:
Telephone Number:*  −  −
Email Address:
Address Information
Street Address:*
(If Military, APO, or FPO Address or if N/A, Next of Kin or Friend.)
City/State/Zip Code:*  /   / 
Number of Years in Residence:
Mailing Address:
(if different than current)
City/State/Zip Code:  /   / 
Previous Address:
City/State/Zip Code:  /   / 
Number of Years in Residence:
Applicant Personal Identification Information
Social Security Number:*  −  −   or Tax ID Number: 
Driver's License Number:*
State Issued:*
Date Issued:*  /   / 
Date Expires:*  /   / 
State ID Number:
State Issued:
Date Issued:  /   / 
Date Expires:  /   / 
Other ID:
(Military ID, Tribal ID, etc)
Additional Applicant Information
Number of Dependants:
Ages of Dependants:
Checking Account Number:     Institution or Branch:
Savings Account Number:     Institution or Branch:
If Applying For Secured Credit:* Married  Separated  Unmarried (single, divorced, widowed)
Name of Nearest Relative:*
(not living with you)
Relative's Street Address:*
City/State/Zip Code:*  /   / 
Telephone Number:*  −  −
Applicant Employment Information
Present Employer:*
Work Address:
City/State/Zip Code:  /   / 
Years Employed with this company:
Name of Supervisor:
Annual Gross Salary:* $ .00
Present Net Salary or Commission: %
Hourly Wage:
(if applicable)
Hours Worked per Week:
Previous Employer:
Years Employed with this company:
Previous Employer Address:
City/State/Zip Code:  /   / 
Other Income Amount: $    Weekly  Monthly  Yearly 
Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.
Alimony, child support or separated maintenance income received under: Court Order  Written Agreement  Oral Understanding
Source of Other Income:
Is any income in this section likely to be reduced before the credit requested is paid off? No Yes     If Yes, Explain:
List All Assets Owned
Note: Please provide the following information for both the Applicant and the Co-Applicant:
Description of Assets Value Subject to Debt Names of Owners
$ Yes No
Automobiles (Make, Model, Year)
$ Yes No
Automobiles (Make, Model, Year)
$ Yes No
Cash Value of Life Insurance
(Issuer, Face Value)
$ Yes No
Real Estate (Location, Date Acquired)
$ Yes No
Marketable Securities
(Issuer, Type, No. of Shares)
$ Yes No
Other (List)
$ Yes No
Total: $
Outstanding Debts
Note: Include charge accounts, installment contracts, credit cards, rent mortgages, etc.
Creditor Type of Debt
or Account #
Name in
Which Account
is Carried
Debt $
Balance $
Payments $
Past Due?
Landlord or Mortgage

(Omit Rent)
(Omit Rent)
Yes  No
Yes  No
Yes  No
Yes  No
Yes  No
Yes  No
Yes  No
Total Debts: $
Do you presently pay:
Type Amount Weekly Monthly
Alimony $
Support $
Maintenance $
Other Monthly Obligations (excluding liability to pay alimony, child support, separate maintenance.)
Is any income listed on this application likely to be reduced before the credit request is paid off? If "Yes",
Are you a co-maker, endorser, or guarantor on any loan or contract? *
  If "Yes", For Whom:
To Whom:
Are there any unsatisfied judgements against you? *
  If "Yes", For Whom:
To Whom:
Have you declared bankruptcy in the last 10 years? *
  If "Yes", For Whom:
To Whom:
Applicant Insurance Information
Please complete the following section if securing this loan with a vehicle or property.
Insurance Agent:
Insurance Agent Address:
City/State/Zip Code:  /   / 
Insurance Agent Telephone:  −  −
Secured Credit
Note: Complete only if credit is to be secured.
Briefly describe the property to be given as security:
Names and Addresses of All Co-Owners of the Property:
Name 1:  
Name 2:  
Name 3:  
If the Security is Real Estate, Give the Full Name of Your Spouse (if any):
By completing this loan application, you certify that the information in it and on any attachments is correct and you authorize Impact Bank to verify such information, to obtain credit reports, to verify any other credit references, and to make such other investigation as Impact Bank deems appropriate. UPDATED FINANCIAL INFORMATION: Impact Bank may request from reporting agencies from time to time credit reports on you and request new financial information directly from you or others for the purpose of updating Impact Bank records. You agree to promptly provide such financial information to Impact Bank. Impact Bank may rely on such information to make credit decisions concerning your loan. You agree to notify Impact Bank of any adverse change in your financial condition.

CREDIT DISCLOSURES: An insurance product may be offered with this product. If an insurance product is offered an extension of credit cannot be conditioned on either of the following: (1) Your purchase of an insurance product from this Bank or any of our affiliates; or (2) Your agreement NOT to obtain, or a prohibition on you from obtaining, an insurance product from an unaffiliated entity. By signing this Application you agree that you have read and understand these Disclosures.
Applicant Signature:*
Co- Applicant Signature:
(where applicable)
You may transmit this application via the Internet, but the loan will not be official until you sign the appropriate loan documents at the Impact Bank office.