Kincannon Funeral Home

Credit Application
Please complete the following form.
Thank you

APPLICANT'S RELATIONSHIP TO THE DECEASED
 		 DECEASED NAME
 
NAME OF APPLICANT
 		 AGE
 		 DATE OF BIRTH
 		 SOCIAL SECURITY
 
PRESENT ADDRESS
 		 CITY
 		 STATE
 		 ZIP CODE
 		 HOW LONG
 		 HOME PHONE
 
PREVIOUS ADDRESS
 		 ZIP CODE
 		 HOW LONG
 
PRESENT EMPLOYER
 		 EMPLOYER ADDRESS
 		 CELL/PAGER #
 		 BUSINESS PHONE
 
OCCUPATION
 		 YEARS ON PRESENT JOB
 		 GROSS MONTHLY SALARY OR WAGE
 
PREVIOUS EMPLOYER
 		 ALIMONY, CHILD SUPPORT, OR SEPARATE MAINTENANCE INCOME NEEDS NOT BE REVEALED IF YOU DO NOT WISH TO HAVE IT CONSIDERED AS A BASIS FOR REPAYING THIS OBLIGATION
 		 OTHER MONTHLY INCOME
 
YEARS ON PREVIOUS JOB
 		 NO. OF DEPENDENTS

 		 CURRENT TOTAL MONTHLY INCOME



 
DRIVERS LICENSE SOURCE OF OTHER INCOME
RENT OR OWN

 		 MONTHLY HOUSING COST
 		 1ST MORTGAGE BAL $

 		 2ND MORTGAGE/HOME EQUITY BAL $

 		 HOUSING COST PAID TO:
 
MY CHECKING ACCOUNT IS WITH

 		 MY SAVINGS ACCOUNT IS WITH
 		 LAST CAR FINANCED OR LEASED BY:
 		 ACTIVE:

 		 DATE PAID OUT:

 
NEAREST RELATIVE NOT SAME ADDRESS
 		 RELATIONSHIP
 		 ADDRESS
 		 PHONE
 
ANOTHER RELATIVE OR PERSONAL REFERENCE
 		 RELATIONSHIP

 		 ADDRESS

 		 PHONE

 
INFORMATION ON CO-APPLICANT. COMPLETE THIS SECTION ONLY IF ANOTHER PERSON WILL BE CONTRACTUALLY LIABLE FOR REPAYMENT WITH APPLICANT. IF APPLICANT IS RELYING ON THE INCOME OF ANOTHER PERSON OR ON ALIMONY, CHILD SUPPORT OR MAINTENANCE INCOME FROM ANOTHER PERSON FOR REPAYMENT, COMPLETE THIS SECTION ABOUT THAT PERSON.
NAME OF APPLICANT
 		 AGE
 		 DATE OF BIRTH
 		 SOCIAL SECURITY
 
PRESENT ADDRESS
 		 CITY
 		 STATE
 		 ZIP CODE
 		 HOW LONG
 		 HOME PHONE
 
PREVIOUS ADDRESS
 		 ZIP CODE
 		 HOW LONG
 
PRESENT EMPLOYER
 		 EMPLOYER ADDRESS
 		 CELL/PAGER #
 		 BUSINESS PHONE
 
OCCUPATION
 		 YEARS ON PRESENT JOB
 		 GROSS MONTHLY SALARY OR WAGE
 
PREVIOUS EMPLOYER
 		 ALIMONY, CHILD SUPPORT, OR SEPARATE MAINTENANCE INCOME NEEDS NOT BE REVEALED IF YOU DO NOT WISH TO HAVE IT CONSIDERED AS A BASIS FOR REPAYING THIS OBLIGATION
 		 OTHER MONTHLY INCOME
 
YEARS ON PREVIOUS JOB
 		 NO. OF DEPENDENTS

 		 CURRENT TOTAL MONTHLY INCOME



 
DRIVERS LICENSE SOURCE OF OTHER INCOME
RENT OR OWN

 		 MONTHLY HOUSING COST
 		 1ST MORTGAGE BAL $

 		 2ND MORTGAGE/HOME EQUITY BAL $

 		 HOUSING COST PAID TO:
 
MY CHECKING ACCOUNT IS WITH

 		 MY SAVINGS ACCOUNT IS WITH
 		 LAST CAR FINANCED OR LEASED BY:
 		 ACTIVE:

 		 DATE PAID OUT:

 
NEAREST RELATIVE NOT SAME ADDRESS
 		 RELATIONSHIP
 		 ADDRESS
 		 PHONE
 
ANOTHER RELATIVE OR PERSONAL REFERENCE
 		 RELATIONSHIP

 		 ADDRESS

 		 PHONE

 
A CONSUMER CREDIT REPORT OR REPORTS MAY BE REQUESTED FROM ONE OR MORE CONSUMER REPORTING AGENCIES (CREDIT BUREAUS) IN CONNECTION WITH THIS APPLICATION. SUBSEQUENT CONSUMER CREDIT REPORTS MAY BE REQUESTED OR USED IN CONNECTION WITH ANY UPDATE, RENEWAL OR EXTENSION OF THE CREDIT REQUESTED BY THIS APPLICATION. IF YOU REQUEST, YOU WILL BE INFORMED WHETHER ANY CONSUMER CREDIT REPORT WAS REQUESTED AND, IF SO, THE NAME OF THE CONSUMER REPORTING AGENCY OR AGENCIES WHICH FURNISHED THE REPORT.

EVERYTHING I HAVE STATED IN THIS APPLICATION IS CORRECT TO THE BEST OF MY KNOWLEDGE, I UNDERSTAND YOU WILL RETAIN THIS APPLICATION WHETHER OR NOT IT IS APPROVED. YOU OR YOUR ASSIGNEE ARE AUTHORIZED TO CHECK MY CREDIT AND EMPLOYMENT HISTORY AND TO ANSWER ANY QUESTION ABOUT YOUR CREDIT EXPERIENCE WITH ME.
SIGNATURE OF APPLICANT
 		 DATE
 		 SIGNATURE OF CO-APPLICANT
 		 DATE
 

APPLICATION SENT BY:                        Kincannon Funeral Home                                                          

CALL DECISION BACK TO:                     Gary Kincannon                                                                                   

PHONE NUMBER:                                          580-482-1800                                                                                            

AMOUNT REQUESTED:                                                                                                                                                            

TERM REQUESTED:                                                                                                                                                                  

 

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