Please complete form online and mail completed form to:
Haywood EMC
376 Grindstone Road
Waynesville, NC 28785

Heat Pump/Weatherization Credit Application
 
HEMC ACCT #
Term of Loan
(Term of loan can be up to 5 Years at approximately 7.9% Interest
Years
Amount of loan requested
Personal Information
Name
Spouse's Name

Applicant
Social Security #

- -
Home Phone #
Address City
State How long at current address
Former Address City
State Applicant's Date Of Birth / /
Name, address, phone # of nearest relative not living with you and relationship    
Employment Information
Present Employer Years Employed

Address
State
Zip

Phone #
Supervisor's Name Position/Title
Previous Employer Years Employed
Address
State
Zip 		Phone #
Supervisor's Name Position/Title
Income Information
Salary Net: $ per week/month/year Gross: $ per week/month/year
Other Income $: Source

** Alimony, child support or separate maintenance income need not be revealed if you do not wish it to be considered as a basis
for repaying this loan.

Is any income listed likely to be reduced within the next two years? Yes No
If yes, please explain:
**The applicant hereby authorizes Haywood EMC to investigate the applicant's credit history and to disclose credit information to credit
reporting agencies.

 
Account #
Location
Amount
Checking Account
Savings Account
Other
Outstanding Debts (PLEASE LIST EVERYTHING)
Type of Loan
Creditor Name
Account #
Monthly Payment
Date of Loan

Past Due
Y or N

Credit Cards

 








Mortgage
Auto Loan
Insurance
Utilities
Other
Totals
         

Are there any other persons obligated on any of the above loans? Yes No
If yes, which ones and who?
Are you a Co-Signer on any loans? Yes No
If yes, for whom and to whom?
Have you declared bankruptcy on any loans? Yes No
If yes, explain.
The applicant(s) hereby instruct Haywood EMC to treat the monthly loan repayments due hereunder the same as
my (our) monthly bill for electric
service. Default in payment of the loan will have the same effect as failure to pay for electrical service and will be
cause for disconnection of electrical
service, under the same conditions as apply to disconnection regularly.

______________________________
Signature of Applicant (Seal) Date