Financial Loan Application 2024

Financial Loan Application 2024

Massachusetts Alternative Financing Program
Please take note:

There are a few important and required documents that you will need to submit along with the application. It is best to gather these documents prior to filling out the Financial Loan Application.
1. Formal written quote on the vendor's company letterhead
  - If this is for a vehicle, the quote should include all details, such as the VIN, mileage, and a listing of associated costs that will be rolled into the loan (tax, title, registration, etc.)
2. Identification (include one of the following, cannot be expired)
  - US Driver's License (in or out of state)
  - US Passport (including signature portion)
  - US Armed Forces Identification
  - Identification issued by state agency (e.g. Registry of Motor Vechiles)
3. Proof of Massachusetts Residency (include one of the following, cannot be expired)
  - Massachusetts Driver's License
  - Voter's Registration
  - Utility Bill in your name
  - Non-driver's, state-issued identification
4. Proof of Income (may include one or more of the following)
  - Two (2) Months of the most recent pay stubs
  - Two (2) Years of IRS Income Tax Returns (include all schedules)
  - Government issused benefits award letter (Social security, Department of Veterans Affairs, etc.)
  - Note: If you have additional income, such as rental income, child support and/or alimony, acceptable documentation would include copies of two years of IRS Income Tax Returns or court documents verifying this income
5. Proof of Disability (includes one of the following)
  - SSDI Award Letter
  - Letter from a health care professional stating the nature of the disability
Welcome to the Financial Loan Application, part of the Massachusetts Alternative Financing Program administered by Easterseals Massachusetts.
Note: If applying for a modified vehicle loan you will need:
- Massachusetts Driver's License
- Insurance binder with the loss payee listed as - Berkshire Bank, PO Box 186, East Syracuse, NY 13057 (this document will be required further along in the application process. You will be notified when to submit this document)
Note: If a lien holder is required, all documents listing a lien holder (such as a Bill of Sale) must list - Berkshire Bank, PO Box 186, East Syracuse, NY 13057 (these documents will be required further along in the application process, you will be notify when to submit any further documents)
Note: If you have a Power of Attorney authorized to sign for you, you will need to attach the POA document with this application
To begin the Financial Loan application, click NEXT

Applicant's Employer Information

If RETIRED, please provide name of last employer and length of time employed.
Are you currently employed?*

YesNo
What is your job title?
Employer Name (Company Name)
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer's Phone number
Please enter a valid phone number
Years/Months this job
Applicant's Initials*
Financial Loan Application

Co-Applicant Employer Information

If RETIRED, please provide name of last employer and length of time employed.
Are you currently employed?

YesNo
Employer Name (Company Name)
What is your job title?
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer's Phone Number
Please enter a valid phone number.
Years/Months at this job
Co-Applicant's Initials
Financial Loan Application

Section III: Financial Information

Applicant/Co-Applicant's Monthly Income ($)*

	Applicant	Co-Applicant
1. Gross Wages (From employer/self employment)
2. SSI
3. SSDI
4. VA
5. Pension/Retirement
6. Other (Please describe below)
Total Monthly Income (add lines 1-6)

Description of "Other" income ($)

Applicant/Co-Applicant's Assets ($)*

	Applicant	Co-Applicant
1. Cash in Bank (savings + checking)
2. Retirement Account
3. Other Assets (property, etc.)
Total Assets (add lines 1-3)

Applicant's Monthly Expenses ($)*

	Name of Creditor	Name on Account	Current Balance ($)	Monthly Payment Amount ($)
1. Mortgage/Rent
2. Auto Loan
3. Auto Insurance
4. Credit Cards (total)
5. Phone
6. Utilities
7. Other
Total Monthly Expenses (add lines 1-7)

Co-Applicant's Monthly Expenses ($)

	Name of Creditor	Name on Account	Current Balance ($)	Monthly Payment Amount ($)
1. Mortgage/Rent
2. Auto Loan
3. Auto Insurance
4. Credit Cards (total)
5. Phone
6. Utilities
7. Other
Total Monthly Expenses (add lines 1-7)

What is the total amount you are looking to finance?*
Note: You must have a written estimate with detailed information about the product, price and name of the vendor on the vender's letterhead. Document upload is located at the end of aplication
Amount you estimate that you can pay each month on a new loan ($)*
Applicant/Co-Applicant's Initials*
Financial Loan Application

Section V: Disability/Assistive Technology Information

Person with Disability (If NOT applicant)
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Social Security Number
Do not include dashes
Relationship to Applicant
Current Address (If different from the Applicant's address. P.O. Box is NOT accepted)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Briefly describe the Assistive Technology User's disability*
Briefly describe the device/equipment/service for which the loan is requested*
Briefly describe how the device/equipment/service will assist/improve the user's disability for increased independence, productivity, and/or quality of life:*
Will the Assistive Technology User require training or assistance with installation, customization, or other services to begin using this Assistive Technology?

NoYes
If "YES", please explain what the Assistive Technology User will need and whether they have the resources to cover these costs
Applicant/Co-Applicant's Initials*
Financial Loan Application

Section VI: General Information
Power of Attorney Authorization

If applicable:

Please indicate by checking the option below if you use a signature stamp or are unable to sign and use a power of attorney. This is only if you use a Power of Attorney.
I/We use a signature stamp, sign with an identifying mark or have power of attorney
Note: At the end of this application, please attach a copy of the power of attorney documentation.
Applicant/Co-Applicant's Initials*
Financial Loan Application

Privacy Rights Notice

Your right to privacy is important to us, and we take steps to ensure this for each and every applicant to the Massachusetts Alternative Finance Program (MAFP). State and federal laws require us (and most other financial institutions) to disclose our privacy policy to you. Please take a moment to review this information, so you can better understand why we collect certain information and how we keep your personal information private.
Information We Collect

We collect two types of personal information about you, but only when that information is provided by you or is obtained by us with your consent. The first type of information is required to determine your loan eligibility, such as financial information. The second type of information is regarding your race, gender, and primary language. This information is not shared with the lender. Only the Massachusetts Alternative Finance Program will use this information to compile statistical analysis for required yearly reporting to the federal government. We may obtain this information in various ways. Some examples include interviews, letters, mailings, and phone calls with you, as well as from the application form you submit to the program or lender.
Parties To Whom We Disclose Information

We disclose personal and financial information about our loan applicants to lending institution(s) who consider granting loans to individuals referred by the Program. We also reserve the right to provide limited personal information to an external evaluator, to measure customer satisfaction or to request an interview about the Massachusetts Alternative Finance Program itself. We may also disclose applicant or participant information to:
- a lender or its agents in the course of a regulatory audit
- persons authorized by a state or federal organization to review the Massachusetts Alternative Finance Program's practices.
As allowable by law, we may also disclose information about an applicant or participant as necessary to carry out a transaction requested or authorized, to service or maintain an account the applicant or participant may hold with the Massachusetts Alternative Finance Program or the lender in connection with an extension of credit.

In addition, with your prior permission, we may provide your contact information to a media contact for purposes of advertising the Massachusetts Alternative Finance Program. You have the option of declining to take part in any advertising and your decision to opt out of this type of activity will have no impact on your application and/or loan status.

Except for these above-listed situations, we do not disclose personal information about current or former applicants to any third party.
Types Of Information We May Disclose

To help you obtain a loan, we may disclose the following types of nonpublic personal information about you:
- Information we receive from you, such as your name, address, social security number, assets and income
- Information about your transactions with us or any other lender(s) who receive your application
- Information we receive from a lender that considers your application or makes you a loan.
Confidentiality And Security Of Non-Public Information

Confidentiality is of the utmost importance to us. We restrict access to your nonpublic, personal information to only those parties who must use the information to provide Program services to you, or to perform the functions previously described. We also protect your personal information from access, alteration, or destruction by maintaining physical, electronic, and procedural safeguards in compliance with applicable laws and regulations.
Non-Discrimination

The Massachusetts Alternative Finance Program does not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, or disability in its programs, activities, or employment practices.
We appreciate your business, and thank you for allowing us to serve your assistive technology financing needs. We are committed to protecting your privacy. Please call the Massachusetts Alternative Finance Program at (508) 751-6431 if you have any questions or concerns abou this Privacy Notice.
By initialing below, you agree that you have read, understand, and agree to the Massachusetts Alternative Finance Program Privacy Rights Policy.
Applicant/Co-Applicant's Initials*
Financial Loan Application

Information Release Authorization

I understand that the Massachusetts Alternative Finance Program (MAFP) will refer me to financial counseling in order to attempt to correct my delinquency on the loan through the MAFP. Upon choosing a credit counseling agency, I will notify the program of the contact information. I understand that this will consist of my participating in a debt management and budgetary session(s) designed to explore repayment options. I understand that the parties involved will collect credit history and credit score information, as well as current financial status, including, but not limited to:

current income, current financial obligations, and discretionary monies, as well as other personal financial information. I also authorize that the MAFP and the credit counseling agency of my choosing to have a reciprocal agreement and my signature below allows these organizations, including designated representatives from each, to communicate with each other and share relevant information. The information shared will be any they deem necessary to determine repayment options.

I understand that all information gathered by and shared between the MAFP and a credit counseling agency of my choosing will be kept confidential, and no information they obtain will be available to unauthorized third parties.

By signing this release, I give full authorization to the staff persons of the MAFP to collect and share information as noted above.
Applicant's Digital Signature*

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Date*

MonthDayYear
Date
Co-Applicant's Digital Signature

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Date

MonthDayYear
Date
Financial Loan Application

Authorization

I/We certify that each of us is 18 years of age or older and is a legal resident of the Commonwealth of Massachusetts. This Authorization is being provided in connection with my/our application to participate in the Massachusetts Alternative Finance Program (the “Program”).

I/We acknowledge and agree that I/We have been provided with a copy of the privacy policy of Easterseals Massachusetts (the “Lender”). I/We understand and acknowledge that the information that I/we provide to the Lender and any information that may be obtained during the course of reviewing my/our application, including non-public personal information, may be shared by the Lender in connection with the processing, review and/or approval of my/our application, and I/We hereby authorize the Lender to share such information between themselves for this purpose, as well as any correspondence or other written communications from them to me/us.

I/We also understand, acknowledge and agree that representatives from the Lender may communicate with third parties who have agreed to accept my/our application in order to enable me/us to participate in the Program, although I/we understand that the Lender will not share with such third parties non-public personal information that is not included in my/our application. I/we further understand that all communications with me/us concerning the status of my/our application will come from the Lender.

I/we authorize health-related information as the Lender reasonably requires in connection with its review of my/our application, provided, however, that I/we understand that any health information provided on this application will not adversely impact my/our application, but is being provided only to establish my/our eligibility for participation in the Program.

I/we also authorize the Lender to disclose any information that I/we provide in connection with this application, including any health information, to any other third party to whom such disclosure is necessary for the purpose of review or oversight of the Program.

I/we authorize the Lender to investigate my/our credit and employment histories and to report the credit experience of any party or authorized user to my/our consumer reporting agencies and others. I/we understand the Lender will retain the application whether or not it is approved.

At any time after this application and during my/our relationship with the Lender, I/we authorize the Lender to obtain information concerning my/our employment and credit standing and authorize my/our employer, banks, and/or other listed reference to release any requested information to the Lender. I/we agree to notify the Lender immediately of any material change in the information provided on this application.

I/we attest that all information provided to the Lender in connection with my/our application is complete and correct in all respects, including a true and accurate statement of my/our current financial position. I acknowledge that it is a federal offense to knowingly make any false statements or reports or willfully overvalue any property for the purpose of influencing the Lender to act on this application.
Applicant's Digital Signature*

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Date*

MonthDayYear
Date
Co-Applicant's Digital Signature

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Date

MonthDayYear
Date
Financial Loan Application

Certification and Signatures

I/We certify that I/We have read and understood this loan application. I/We understand that this is a request for funds that I will need to repay without interest on a monthly basis. Failure to repay will result in further action determined during time of collection. I/We understand that any incorrect or misleading information on the application and/or attachments could result in rejection of the loan request or temination of the loan.

I/We understand the information contained in the application will be used to reveiew and approve or deny the request for credit. I/We hereby authorize Easterseals of Massachusetts, Inc., their loan committee (if required) and Berkshire Bank to verify that the information contained in the loan application is correct.

I/We acknowledge that Easterseals of Massachusetts Inc., and Berkshire Banck have access to this application and any other information attached to the application or obtained in reviewing the loan request. I/We understand that these two entities have the right to exchanged my/our personal information with each other in relation to the application, including information obtained from credit reports, income statements, bank statements, or any other information pertinent to processing the loan request.

I/We give Easterseals of Massachusetts Inc., and/or Berkshire Bank authoriazation to make all inquiries deemed necessary to verify the accuracy of information contained herein and to determine the creditworthiness of the undersigned.

I/We undestand the Easterseals of Massachusetts Inc., and Berkshire Bank are not responsible if the requested assistive technology does not funtion or is not suitable to my/our needs. I/We unserstand it is my/our responsibility for repairs, maintanance, and insurance (if applicable) unless specified elsewhere during he loan approval process.
Applicant's Digital Signature*

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Date*

MonthDayYear
Date
Co-Applicant's Digital Signature

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Date

MonthDayYear
Date
Financial Loan Application

Applicant Certification

You certify that to the best of your knowledge everything you have stated in this credit application, and on any other documents submitted to us, are true and corrct as of the date set forth opposite your signature. You have no other debts other thatn those listed above. You understand that you must update the information contained in this application if either you financial condition materially changes or we make a request to uou orally or in writing. You understand that we will retain this credit and employment history. Upon your request, we will tell you if a credit report as obtained and give you the name and address of the credit reporting agncy that provided the report. The information the Lender obtains is to be used in the processing of your consumer loan application or in conjunction woth the quality control review of the file after the loan has closed. The lender may further, request such credit information at any time after the extention of credit has been approved for the purpose of renewal, continuation, or collection of the account.

ECOA Notice

The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, sexual orientation, marital status, age (provided the applicant has the capacity to enter into a binding contract), because all or part of the applicant's income derives from any public assistance program, or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The Federal agency that administers compliance with this law concerning the creditor is Bureau of Consumer Financial Protection, 700 G Street NW, Washington DC 20006.
Applicant's Digital Signature*

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Date*

MonthDayYear
Date
Co-Applicant's Digital Signature

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Date

MonthDayYear
Date
Financial Loan Application

Consent to Obtain Credit Report

I/We authorize Berkshire Bank to order a consumer credit report and verify other credit information. I/We agree that the Bank may exchange credit information about me/us with other affiliates, credit bureaus and agencies. I/We agree that the Bank may also request any information necessary to process this request, such as income/employment and assets. It is understood that a photocopy of this form will also serve as authorization.

The information the Bank obtains is to be used in the processing of my/our Easterseals Alterative Finance Program application or in conjunction with quality control review of the file after the loan has closed. The Lender may further, request such credit information at any time after the extension of credit has been approved for the purpose of review or collection of the account.
Applicant's Digital Signature*

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Date*

MonthDayYear
Date
Co-Applicant's Digital Signature

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Date

MonthDayYear
Date
Financial Loan Application

Acknowledgement of Intent to Apply for Joint credit

Only sign if applying with a co-applicant.

We certify that we each intend to apply jointly for credit and the income or assets of each person will be used as a basis for loan qualification.
Applicant's Digital Signature

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Date

MonthDayYear
Date
Co-Applicant's Digital Signature

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Date

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Applicant/Co-Applicant's Initials*
Financial Loan Application

Section VII: Supporting Documents

All required documents
Formal written quote on the vendor's company letterhead

Note: If this application is for a vehicle, the quote should include all details, such as the VIN, mileage, and a listing of associated costs that will be rolled into the loan (tax, title, registration, etc.)
Vendor Letterhead _ File Upload

Please attach all supporting documents prior to submitting your application.
Cancelof
Financial Loan Application

Identification (Include one of the following, cannot be expired)
- US Driver's License (In or out of state)
- US Passport (Including signature portion)
- US Armed Forces Identification
- Identification issued by a state agency (e.g. Registry of Motor Vehicles)
Identification _ File Upload

Please attach all supporting documents prior to submitting your application.
Cancelof
Financial Loan Application

Proof of Massachusetts Residency (Include one of the following, cannot be expired)
- Massachusetts Driver's License
- Voter's Registration
- Utility Bill in your name
- Non-driver's, state-issued identification
Proof of Massachusetts Residency _ File Upload

Please attach all supporting documents prior to submitting your application.
Cancelof
Financial Loan Application

Proof of Income (May include one or more of the following)
- Two (2) Months of the most recent pay stubs
- Two (2) Years of IRS Income Tax Returns (include all schedules)
  Government issused benefits award letter (Social security, Department of Veterans Affairs, etc.)
Note: If you have additional income, such as rental income, child support and/or alimony, acceptable documentation would include copies of two years of IRS Income Tax Returns or court documents verifying this income
Proof of Income _ File Upload

Please attach all supporting documents prior to submitting your application.
Cancelof
Financial Loan Application

Proof of Disability (Include one of the following)
- SSDI Award Letter
- Letter from a healh care professional stating the nature of the disability
Proof of Disability _ File Upload

Please attach all supporting documents prior to submitting your application.
Cancelof
Financial Loan Application

Power of Attornery (If applicable)

If you have a Power of Attorney authorized to sign for you, please send the POA document with this application
Power of Attorney _ File Upload

Please attach all supporting documents prior to submitting your application.
Cancelof
Financial Loan Application

All Other Supporting Documents
All Other Documents _ File Upload

If applicable
Cancelof
Financial Loan Application

Prior to submitting, please make sure that you:
- Completed all parts of the application
- Signed and dated the application where needed
- Initialed the application where needed
- Submitted applicable documents
Financial Loan Application
Should be Empty:

	Approved	Denied	Pending Decision
Medical Assistance
School District
Vocational Rehabilitation
Insurance
Medicare
Other

	Yes	No
Do you currently have any outstanding judgements or have you ever filed for bankruptcy, had a debt adjustment plan confirmed under Chapter 13, had property foreclosed upon or repossessed in the last 7 years, or been a party in a lawsuit?
Have you any obligations not listed in this application?
Are you a co-maker, co-signer or guarantor on any loan? (if yes, please provide details)

	Yes	No
Do you currently have any outstanding judgements or have you ever filed for bankruptcy, had a debt adjustment plan confirmed under Chapter 13, had property foreclosed upon or repossessed in the last 7 years, or been a party in a lawsuit?
Have you any obligations not listed in this application?
Are you a co-maker, co-signer or guarantor on any loan? (if yes, please provide details)

Financial Loan Application 2024

Section I: Applicant Information

Applicant's Employer Information

Section II: Co-Applicant Information

Co-Applicant Employer Information

Section III: Financial Information

Section IV: Demographic Information

Section V: Disability/Assistive Technology Information

Disability/Assistive Technology Information

Section VI: General Information

Section VII: Supporting Documents