Personal / English

Personal Loan Preapplication

Use this form to describe your request, income and current obligations. Save sensitive records for a secure follow-up.

Do not fill this out:

01 Applicant and request

Full legal name *Email *Phone *Last four digits of SSN

Last four only. Do not submit your full Social Security number.

Home address *Time at current addressHousing status * Amount requested *When are funds needed? *Preferred term in monthsDesired monthly paymentLoan preferencePreferred bank or providerPurpose and details *

02 Employment and income

Employment status *OccupationEmployer or business nameEmployment start dateEmployer phonePrevious employer, if current employment is under 2 yearsGross monthly employment income *Net monthly employment incomeNet monthly self-employment incomeMonthly retirement or benefitsOther monthly incomeSource of other incomeTotal gross monthly income relied on *Most recent tax year and annual incomeExpected income changes or seasonal variation

03 Monthly expenses

Rent or mortgage *Other housing costsUtilitiesFoodTransportationInsuranceSupport obligationsOther recurring expenses

04 Debts and credit

List major obligations. Do not include account numbers.

Debt 1

Creditor and typeBalanceMonthly paymentWould be repaid with requested funds

Debt 2

Creditor and typeBalanceMonthly paymentWould be repaid with requested funds

Debt 3

Creditor and typeBalanceMonthly paymentWould be repaid with requested funds

Total monthly debt, including housing *Estimated credit score range

05 Financial position

Savings and liquid assetsPrimary bank relationship and yearsPotential collateral, estimated value and known liens

Any past-due debts or collections? *

Yes No

Any bankruptcy, foreclosure or default in the last 7 years? *

Yes No

Explain any yes answers

06 Records available

Check what you can provide later through an agreed secure method. Do not upload or email these records now.

07 Acknowledgement

This is a preliminary request for information. It is not a credit application, offer, approval or commitment to provide financing. Derivitas Group is not a lender and does not make credit decisions. Any provider independently determines eligibility, underwriting, rates, fees and terms.

By submitting, I confirm that the information is accurate to the best of my knowledge and authorize Derivitas to contact me about this request and share the information with relevant independent financing providers when appropriate.

Typed full name *Date *

I have read and agree to the acknowledgement above. *

Your information will be submitted to Derivitas for preliminary review.