1H Check the box that most closely corresponds to current marital status of the Marital Status or the entity member, if an individual. Items 1I 1L Voluntary Information for Monitoring Purposes (Complete as applicable) – – 1I Check the appropriate box indicating your ethnicity. Ethnicity 1J Check the appropriate box or boxes indicating your race. Race 2K Check the appropriate box indicating your gender. Gender 2L Check the appropriate box indicating your veteran status. Veteran Status Note: If additional Co-Applicants or Entity Members, complete Items 2A 2L and/or Items 3A 3L – – in the same manner. Additional copies of Pages 5 and 6 may be attached if necessary. Part O Co-Applicant or Entity Member Certifications – Certification/ Please read the statements in this section carefully before signing. Acknowledgment 1A Enter the signature of the co-applicant or entity member. Signature of Co-Applicant or Entity Member 1B Check if you are signing for yourself. Check if you “Self” “Entity Representative” Capacity are signing on behalf of an entity. 1C Enter the date the co-applicant or entity member signed the form. (MM-DD-YYYY) Date Note: If additional Co-Applicants or Entity Members, complete Items 2A 2C and/or Items 3A 3C in – – the same manner. Additional copies of Pages 5 and 6 may be attached if necessary.
1H Marital Status Check the box that most closely corresponds to current marital status of the or the entity member, if an individual. Items 1I – 1L – Voluntary Information for Monitoring Purposes (Complete as applicable) 1I Ethnicity Check the appropriate box indicating your ethnicity. 1J Race Check the appropriate box or boxes indicating your race. 2K Gender Check the appropriate box indicating your gender. 2L Veteran Status Check the appropriate box indicating your veteran status. Note: If additional Co-Applicants or Entity Members, complete Items 2A – 2L and/or Items 3A – 3L in the same manner. Additional copies of Pages 5 and 6 may be attached if necessary. Part O – Co-Applicant or Entity Member Certifications Certification/ Acknowledgment Please read the statements in this section carefully before signing. 1A Signature of Co-Applicant or Entity Member Enter the signature of the co-applicant or entity member. 1B Capacity Check “Self” if you are signing for yourself. Check “Entity Representative” if you are signing on behalf of an entity. 1C Date Enter the date (MM-DD-YYYY) the co-applicant or entity member signed the form. Note: If additional Co-Applicants or Entity Members, complete Items 2A – 2C and/or Items 3A – 3C in the same manner. Additional copies of Pages 5 and 6 may be attached if necessary.
FSA_2210_Instructions_Application_EZ_Guarantee-1.docx