Uniform Residential Loan Application - 2009 Page 10

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FEDERAL CREDIT APPLICATION INSURANCE DISCLOSURE
I have applied for an extension of credit with you. You are soliciting, offering, or selling me an insurance
product or annuity in connection with this extension of credit.
FEDERAL LAW PROHIBITS YOU FROM
CONDITIONING THE EXTENSION OF CREDIT ON EITHER:
1.
My purchase of an insurance product or annuity from you or from any of your affiliates; or
2.
My agreement not to obtain, or a prohibition on me from obtaining, an insurance product or annuity
from an unaffiliated entity.
By signing, I acknowledge that I have received a copy of this form on today's date. Unless this disclosure is
provided electronically or I have applied for credit by mail, I also acknowledge that you have provided this
disclosure to me orally.
...........................................................................
...........................................................................
Consumer
Date
Consumer
Date
(page 1 of 1)
2001 Bankers Systems, Inc., St. Cloud, MN Form INS-FED 2/15/2001
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