AMEDDApplicantWorksheet-July2012-3.doc

Financial obligations for which you where the sole

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financial obligations for which you where the sole debtor as well as those where you were a cosigner or guarantor) In the past seven (7) years , you had any account or credit card suspended, charged off, or cancelled for failing to pay as agreed? (Include financial obligations for which you where the sole debtor as well as those where you were a cosigner or guarantor) In the past seven (7) years , you were evicted for non-payment? In the past seven (7) years , you had your wages, benefits, or assets garnished or attached for any reason? In the past seven (7) years , you have been over 120 days delinquent on any debt not previously entered? (Include financial obligations for which you where the sole debtor as well as those where you were a cosigner or guarantor) You are currently over 120 days delinquent on any debt? (Include financial obligations for which you where the sole debtor as well as those where you were a cosigner or guarantor) Include question number and explain all ‘YES’ answers without prior explanation to include the following information: Date (dd-MMM-yyyy) Financial issue began, Type of Action, Amount (USD), Account Number, Name of Agency/Organization/Individual to whom Debt is/was owed, Name Action Occurred Under, Status of Action, Explanation, Court/Agency Name and Address. FAMILY & ASSOCIATES 52
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Complete all entries that apply to the best of your knowledge. Mother and Father information is required. If married, provide Spouse, Mother in Law and Father in Law information. If divorced, Former Spouse information is required. For any family member that is deceased, provide only name, birth date and place of birth information. SSNs are required for those you will list as beneficiaries. If anyone was not born in the U.S., but currently reside in the U.S., provide citizenship information. Relationship: (Mark ‘X’ to one that applies) Adult Living w/you Associate Brother Cohabitant Child (custody) Father Father in Law Former Spouse Foster Parent Guardian Half Brother Half Sister X Mother Mother in Law Other Relative Sister Stepbrother Stepchild Stepfather Stepmother Stepsister Last Name: Maiden Name: Deceased? Y/N First Name: Dependent? Y/N Gender: Middle Name: Suffix: Adopted? Y/N Date of Birth: (dd-MMM-yyyy) Approximate? Y/N Has this relative used any other names? Name: Dates used: From To Use Applicant’s Current Address? Y/N Use Applicant’s Home of Record? Y/N Street: City: State: Zip Code: Country: Place of Birth: City: State: Country: Country(ies) of Citizenship: Citizenship Document Information: (i.e. Naturalization Cert., U.S. Passport, Alien Reg., etc.) Certificate/Registration No.: Date Issued (dd-MMM-yyyy): City/State: Court: Relationship: (Mark ‘X’ to one that applies) Adult Living w/you Associate Brother Cohabitant Child (custody) X Father Father in Law Former Spouse Foster Parent Guardian Half Brother Half Sister Mother Mother in Law Other Relative Sister Stepbrother Stepchild Stepfather Stepmother Stepsister Last Name: Maiden Name: Deceased? Y/N First Name: Dependent? Y/N Gender: Middle Name: Suffix: Adopted? Y/N Has this relative used any other names? Name:
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