1I Check the appropriate box to indicate the individual marital status. member’s Marital Status 1J Check the appropriate box to indicate the individual status as a member’s Citizenship citizen, non-citizen national or qualified alien. 1K Check the appropriate box to indicate the individual ethnicity. member’s *Ethnicity 1L Check the appropriate box to indicate the individual race. member’s *Race 1M Check the appropriate box to indicate the individual gender. member’s *Gender 1N Check if applicant is a veteran. Check if not a veteran. “YES, “NO”, Veteran Status 1O Check the appropriate box indicating if the information collected was provided FSA Use Only or observed. 2A Enter description of assets owned by the individual member. Assets Description 2B Enter the dollar value of each asset listed. Value 3 Add the value of each asset listed in 2B above and enter the total dollar value Total Assets here. 4A List the name(s) of creditors. Creditor 4B Enter the annual dollar amount of payments due to each of the creditors listed. Payment 4C Enter the total balance due (as of Balance Sheet Date) to each of the creditors Balance listed. 5 Add the balance due for each debt listed in 4C above and enter the total dollar Total Debts value here. 6 Enter the dollar amount from Item 3. Total Assets 7 Enter the dollar amount from Item 5. Total Debts 8 Subtract Item 7 from Item 6 and enter the dollar amount here. Net Worth 9 Enter the individual signature to indicate that they have read the member’s Signature statements and certifications on Pages 3 through 5. 10 Enter the date the individual member signed the form. Date
1I Marital Status Check the appropriate box to indicate the individual member’s marital status. 1J Citizenship Check the appropriate box to indicate the individual member’s status as a citizen, non-citizen national or qualified alien. 1K *Ethnicity Check the appropriate box to indicate the individual member’s ethnicity. 1L *Race Check the appropriate box to indicate the individual member’s race. 1M *Gender Check the appropriate box to indicate the individual member’s gender. 1N Veteran Status Check “YES, if applicant is a veteran. Check “NO”, if not a veteran. 1O FSA Use Only Check the appropriate box indicating if the information collected was provided or observed. 2A Assets Description Enter description of assets owned by the individual member. 2B Value Enter the dollar value of each asset listed. 3 Total Assets Add the value of each asset listed in 2B above and enter the total dollar value here. 4A Creditor List the name(s) of creditors. 4B Payment Enter the annual dollar amount of payments due to each of the creditors listed. 4C Balance Enter the total balance due (as of Balance Sheet Date) to each of the creditors listed. 5 Total Debts Add the balance due for each debt listed in 4C above and enter the total dollar value here. 6 Total Assets Enter the dollar amount from Item 3. 7 Total Debts Enter the dollar amount from Item 5. 8 Net Worth Subtract Item 7 from Item 6 and enter the dollar amount here. 9 Signature Enter the individual member’s signature to indicate that they have read the statements and certifications on Pages 3 through 5. 10 Date Enter the date the individual member signed the form.
FSA_2330_Instructions_Microloan_Application.docx