LOAN RATE MODIFICATION APPLICATION

LOAN RATE MODIFICATION APPLICATION • I am applying for individual credit • We are applying for joint credit Please initial below. id BankWell 208 Elm St. New Canaan, CT 06840 (203) 972-3838 Applicant Co-Applicant Current Rate Modification Rate Request Purpose RATE REDUCTION APPLICANT CO-APPLICANT Feist Name Middle Initial Last Name First Name Middle Initial Last Name Street Address Street Address City/Town State Zip Code Cily/Town State Zip Code Former Address if less than 2 wars at current address Former Address if less than 2 years al current address City/Town State Zip Code City/Town State Zip Code Social Security Number Home Phone Number Social Security Number Home Phone Number Date of Birth Number of Dependents (including sell) Date ',Mirth Number of Dependents (including self) Nearest Relative not living with you Relationship Nearest Relative riot living with you Relationship APPLICANT OCCUPATION CO-APPLICANT OCCUPATION Employer Employer Address Work Phone Number Address Work Phone Number Position How Long Position How Long Former Employer if in current position less than 2 year% How Long Former Employer if in current position less than 2 years Now Long INCOME INCOME List sources of income below. Income from alimony or child support payments need not be revealed if you do not wish to have it considered as a basis for repaying this loan. List sources of income below. Income from alimony or child support payments need not be revealed if you do not wish to have it considered as a basis for repaying this loan. Gross Monthly Salary Gross Monthly Salary Commissions and Overtime Commissions and Overtime Dividend and Interest Dividend and Interest Rental Rental Other Other EQUAL HOUSING LENDER MEMBER FDIC EFTA00307537 TOTAL TOTAL OUTSTANDING DEBTS (Include charge accounts, installment accounts, credit cards and mortgages. etc. Please use a separate sheet if necessary.) CREDITOR TYPE OR ACCT NUMBER NAME(S) ON ACCOUNT ORIGINAL DEBT CURRENT BALANCE MONTHLY PAYMENTS 0 Mortgage 0 Rent TOTAL DEBTS QUESTIONS APPLICANT CO-APPLICANT EXPLANATION (Please use a separate sheet if necessary.) 0 Yes 0 No 0 Yes 0 No Ilave you ever been declared bankrupt? Are you party to a lawsuit? • Yes • No E Yes • No 0 Yes 0 No 0 Yes 0 No Ilave you ever had credit in another name? 0 Ycs 0 No 0 Yes 0 No Are you obligated to pay alimony, child support or separate maintenance? 0 Yes 0 No 0 Yes 0 No Are you a co-maker, guarantor or endorser on a note? APPLICANT SIGNATURE (S) I/We hereby apply for the loan or credit described in this application. I/We certify that Uwe make no misrepresentations in this loan application or in any related documents, that all information is true and complete, and Ilwe did not omit any important information. Lender is authorized to verify with other parties and to make any investigation of my/our credit, either directly or through any agency employed by Lender for that purpose. Lender may disclose to any other interested party information as to Lender's experiences or transactions with my/our account. IMie understand that Lender will retain this application and any other credit information Lender receives, even if no loan is granted. INie agree to be bound by the terms and conditions in the Credit Agreement and Disclosure, a copy of which will be provided to me/us if the Lender approves this application. APPLICANT: X tpplicant X Date Co-Applicant Date Received by Bank Originator's Signature EQUAL HOUSING LENDER MEMBER FDIC Date EFTA00307538