LUMBEE RIVER ELECTRIC MEMBERSHIP CORPORATION

WEATHERIZATION LOAN APPLICATION

APPLICANT INFORMATION

Last Name First Name Middle Initial

Social Security Number Date of Birth Drivers License Number

Street Address City, State, Zip Telephone Number

Mailing Address City, State, Zip Alternate Telephone Number

Time at Current Residence LREMC Account Number

ABOUT YOUR HOME

Do you OWN or RENT the property in which improvements are to be made?

Age of Home

Heat Source Cooling Source Type of Water Heater

Type of Home (Modular, Mobile, Custom Built, etc.) If mobile, is home under-pined?
EMPLOYMENT & INCOME INFORMATION

Current Employer Position/Job Title How Long?

Address City, State, Zip Business Telephone Number

Gross Salary Annual, Monthly, Weekly, or Hourly? Employment Status (Specify)

Full, Part, Temp, Retired, Other?
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.

Other Income & Source Annual, Monthly, Weekly, or Hourly?

CO-APPLICANT INFORMATION

Last Name First Name Middle Initial

Social Security Number Date of Birth Drivers License Number

Current Employer Position/Job Title How Long?

Address City, State, Zip Business Telephone Number

Gross Salary Annual, Monthly, Weekly, or Hourly? Employment Status (Specify)

Full, Part, Temp, Retired, Other?

UPDATED: January 27, 2010

 OBLIGATIONS
List all obligations (for example, mortgage, auto loan(s), credit cards, etc.)If additional space is need please attached a separate sheet.
Debtor Type Amount Owed Monthly Payment

LOAN AMOUNT & PURPOSE

Amount Purpose
BY SUBMITTING THIS APPLICATION: I/we certify that the information contained herein is true, correct, and complete.
Authorization is hereby granted to all agencies to release credit and financial information to LREMC from time to time, which
LREMC deems necessary to establish and maintain credit.

APPLICANT SIGNATURE DATE CO-APPLICANT SIGNATURE DATE

SUBMIT APPLICATION TO:

Lumbee River EMC
Attn: Misha Melvin
P.O. Box 830
Red Springs, NC 28377

Or

FAX TO:
(910) 843-2652
Attn: Misha Melvin

UPDATED: January 27, 2010