Information Disclosure Authorization

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INFORMATION DISCLOSURE AUTHORIZATION
To Whom it May Concern:
I/We have applied for a mortgage loan through Farmers Trust and Savings Bank (Lender). As
part of the application process, the Lender and any potential investor or insurer of this loan may
verify the information contained in my/our credit application and in other documents required in
connection with this loan.
I/We authorize you to provide to the Lender and to any potential investor or insurer of this loan,
any and all information and documentation requested. Such information may include, but is not
limited to: employment and income history; bank, money market, and similar account balances;
credit history; and copies of income tax returns. The source of the information may come from,
but is not limited to: credit bureaus; banks and other depository institutions; current and former
employers; federal or state records including State Employment Security Agency records; or
other sources as required.
A photographic copy of this authorization (being a photographic copy of the signature(s) of the
undersigned), may be deemed to be the equivalent of the original and may be used as a duplicate
original.
This authorization continues in effect for one (1) year unless limited by state law, in which case
the authorization continues in effect for the maximum period, not to exceed one (1) year, allowed
by law.
_________________________
_____________________
__________________
Signature
Social Security #
Date
_________________________
_____________________
__________________
Signature
Social Security #
Date
Privacy Act Notice: This information is to be used by the agency collecting it in determining
whether you qualify as a prospective mortgagor or borrower under its program. It will not be
disclosed outside the agency without your consent except to your employers(s) for verification of
employment or to financial institutions for verification of your deposits and loans as permitted by
law. You do not have to give us this information, but if you do not your application for approval
as a prospective mortgagor may be delayed or rejected. The information requested in the form is
authorized by Title 38, U.S.C., Chapter 37 (if VA); by 12 U.S.C., Section 1701 et seq. (if
HUD/FHA); by 42 U.S.C., Section 1452b (if HUD/CPD); and Title 42, U.S.C., 1471 et seq.; or 7
U.S.C., 1921 et seq. (if U.S.D., FmHA).

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