Economic Hardship Declaration Form

In an effort to support our Members who are experiencing a financial hardship, we encourage any Member who is experiencing a financial hardship to contact Vantage West Credit Union so we can address your individual financial situation and understand what assistance may be available to you. In order to better prepare a Vantage West Associate to assist you, please complete the following Economic Hardship Declaration.

Please describe in detail your financial hardship situation. *

Please describe in detail how your financial hardship has an impact on your ability to maintain payments on your Vantage West Credit Union loan(s). *

Account Type (If you have both a Consumer and Business relationship, please complete a form for each) *

Consumer

Business

Consumer Name *

Business Name

Guarantor Name *

Phone Number *

Email address *

Products *

Last 4 digits of account number *

How many people currently reside in your household? *

Please use whole numbers (no cents) when using currency.

Monthly Househould Net Income (income after taxes and other deductions) *

Are you currently employed? *

Yes

No

Are you self-employed? *

Yes

No

Current Savings Account Balance (at other financial institutions) *

Current Checking Account Balance (at other financial institutions) *

Investment Accounts (IRA, 401k, mutual funds, stocks, bonds, ETF's, etc.) *

Do you own any property free and clear? (homes, vehicles, ATV's, boats, etc.) *

Yes

No

Do you currently own or rent your residence? *

Rent

Own

Monthly housing payment *

Does your housing expenses include insurance and taxes? *

Yes

No

Yearly insurance premium *

Yearly property taxes

Do you pay HOA dues? *

Yes

No

Monthly HOA dues *

Monthly electric expense *

Monthly Cell phone expense *

Monthly home phone expense *

Monthly trash/Sewage expense *

Monthly cable expense *

Monthly internet expense *

Monthly water expense *

Monthly gas expense *

How many vehicles do you have in your household? *

Monthly Auto Loan payments (please add each vehicle loan)

+-

Total monthly auto insurance premiums *

Monthly fuel cost *

List any credit/loan obligations not covered above and the monthly expense for each obligation

+-

Do you currently have medical/dental coverage through your employer? *

Yes

No

Monthly prescriptions/co-pay/medical/dental costs *

Clothing/Hair Cuts *

Monthly grocery expenses *

Dining out *

Monthly childcare/tuition expenses *

Monthly Whole/Term Life Insurance Premiums *

All loan modifications are subject to Member eligibility, credit union approval, completion of applicable loan documentation, and production of supporting information. Interest continues to accrue during any accommodation. Members are responsible for separately cancelling and/or modifying all automatic transfers and payments. Vantage West reserves all rights and remedies. Submission of this request may result in an inquiry and review of credit reporting for all Members listed on the loan.

This request is due to an economic hardship. The statements made are true and correct. *

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