Combination Promissory Note Truth In Lending Disclosure
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3COMBINATION PROMISSORY NOTE, TRUTH-IN-LENDING DISCLOSURE STATEMENT AND SECURITY AGREEMENT
ITEMIZATION OF THE AMOUNT
Johnson's Title & Payday Loan
LENDER--
$1,125.00
FINANCED OF
123 Anywhere Street
CREDITOR NAME
$1,000.00
New Orleans, Louisianna 30026
& ADDRESS
Amount Given To Me Directly ........
615-789-4568
Amount Paid On My Account ........
BORROWER'S NAME & ADDRESS
AMOUNTS PAID TO OTHERS ON MY BEHALF
(I understand and
LOAN NUMBER:
agree that you receive and retain a portion of certain of these amounts)
TL181
Ronnie C Johnson
AMOUNTS PAID TO INSURANCE COMPANIES FOR:
DATE OF LOAN
1015 East Concord Avenue
(a) Credit Life Insurance ...........
4/5/2006
Goodlettsville, 37072 PARISH: Sumner
Lvl
Sngl
LDcrsng
Jnt
Dsmbrmt
404-04-0404
CO-BORROWER'S
BORROWER'S
(b) Credit Disability Insurance ...
SS/TAX ID #
SS/TAX ID #
7 Day Retr
14 Day Retr
ANNUAL
FINANCE CHARGE
Amount Financed
Total of Payments
The amount I will have
PERCENTAGE RATE
(c) Property Insurance..............
The dollar amount the credit
The amount of credit
paid after all sheduled
The cost of my credit as a
will cost me.
provide to me or on my
payments are made.
AMOUNTS PAID TO PUBLIC OFFICIALS FOR
yearly rate:
behalf.
$125.00
(a) Filing Fee............................
22.00%
$20.40
$1,125.00
$1,145.40
(b) Termination Fee .................
MY PAYMENT SCHEDULE WILL BE:
(c) Real Estate Notary Fee ......
NUMBER
OTHER
$0.00
AMOUNT OF FIRST
FIRST PAYMENT
AMOUNT OF OTHER
FINAL
(d) Non - Real Estate Notary Fee
OF
PAYMENTS
PAYMENT
DUE DATE
PAYMENTS
PAYMENT DUE
PAYMENTS
DUE SAME
AMOUNTS OF OTHER ITEMS PAID:
DAY OF EACH
1
$1,145.40
5/5/2006
$0.00
5/5/2006
SUCCEEDING
To __________________________
MONTH
for Real Estate Appraisal Fee.........
Security: I am giving you a security interest in:
Certain Household Items
Motor Vehicle
To __________________________
Goods or property being purchased
for Title Examination Fee................
Collateral securing other loans may also secure this loan
$0.00
To You for Documentation Fee.......
This Loan is unsecured.
Other (describe)
$25.00
To You for Origination Fee..............
Late Charge. If a payment is more than 10 days late, I will be charged $15,00 or 5% of the delinquent amount,
To __________________________
whichever is less.
Prepayment: If I pay off early, I may be entitled to a refund of part of the finance charge.
for Non Filing Insurance...................
A subsequent purchaser of my dwelling financed under this loan may
Assumption Policy:
To __________________________
not be permitted to assume this loan under its original terms.
for __________________________
I should see my contract documents for any additional information about nonpayment,
To __________________________
default, any required repayment in full before the scheduled date, and prepayment refunds
Credit life insurance and credit disability insurance are not required to obtain credit, and will not be provided
To __________________________
Insurance:
unless I sign and agree to pay the additional cost. Insurance, if provided, is for a a term of __________ months. Amount
of Coverage $___________
To __________________________
To __________________________
TYPE
PREMIUM
SIGNATURE
Reducing
without Dismemberment
with Dismemberment
I want Reducing Credit Life Ins
To __________________________
Term
SIGNATURE:
Credit Life
(Less) Prepaid Finance Charge .....
Level
without Dismemberment
with Dismemberment
I want Level Credit Life Ins
Term
I may obtain required property insurance from
SIGNATURE:
Credit Life
anyone I want that is acceptable to you. If I obtain
Joint
without Dismemberment
with Dismemberment
I/We want Joing Credit Life Ins
the insurance through you the cost will be as follows:
Credit Life
SIGNATURE:
PROPERTY INSURANCE
Credit
I/We want Credit Disability Insur
Disability
for a term of _________________months.
SIGNATURE:
A PORTION OF THE INSURANCE FEES MAY BE RETAINED BY THE SELLER.
As stated above, "I", "Me" or My" means all Borrowers; and "You" means the Lender-Creditor named abo
I (we) further acknowledge receipt of a completed copy of this Truth-in-Lending Disclosure statement, Promissory Note and Security Agreement.
STATE OF LOUISIANA
Sumner
PARISH OF
For identification with an act of RE Mortgage acknowledged before me this
Borrower/Grantor
day of
.
,
Notary Public
Co-Borrower/Grantor
Page 1
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