CLEAR FORM
Non-Purpose Application
Page 1 of 6
APPLICATION
IMPORTANT ACCOUNT OPENING INFORMATION: Federal law requires us to obtain sufficient information to verify your identity. You may be
asked several questions and to provide one or more forms of identification to fulfill this requirement. In some instances, we may use outside
sources to confirm the information. The information you provide is protected by our privacy policy and federal law.
1 APPLICANT/GUARANTOR INFORMATION (CHECK APPLICABLE BOXES)
b
■ APPLICANT b GUARANTOR b CO-APPLICANT b GUARANTOR
INDIVIDUAL
This Section is
RAYMOND VENEZIA KAREN VENEZIA
for Borrower/
APPLICANT/GUARANTOR NAME CO-APPLICANT/GUARANTOR NAME
Co-Borrower
and Guarantor 7380 CEILCREST LN NE SAME AS APPLICANT
information only. HOME ADDRESS (STREET) HOME ADDRESS (STREET)
Complete Section ROCKFORD, MI 49341
Five (5) for Pledgor HOME ADDRESS (CITY, STATE, ZIP) HOME ADDRESS (CITY, STATE, ZIP)
information.
MAILING ADDRESS (STREET) IF DIFFERENT THAN HOME ADDRESS MAILING ADDRESS (STREET) IF DIFFERENT THAN HOME ADDRESS
MAILING ADDRESS (CITY, STATE, ZIP) IF DIFFERENT THAN HOME ADDRESS MAILING ADDRESS (CITY, STATE, ZIP) IF DIFFERENT THAN HOME ADDRESS
(616) 822-0051 (616) 446-2928
CELL PHONE WORK PHONE HOME PHONE CELL PHONE WORK PHONE HOME PHONE
[email protected] [email protected]
EMAIL ADDRESS EMAIL ADDRESS
335-64-8182 05/09/1961 428-11-6275 09/22/1962
SOCIAL SECURITY NUMBER (SSN) DATE OF BIRTH (MM/DD/YYYY) SOCIAL SECURITY NUMBER (SSN) DATE OF BIRTH (MM/DD/YYYY)
Disclosure A
*Alimony, child ■
UNITED STATES CITIZEN b YES b NO UNITED STATES CITIZEN b YES b NO
support, or separate CHECK ONE:
maintenance income
■ DRIVERSbLICENSE b PASSPORT b PHOTO ID CHECK ONE: b
■ DRIVERS LICENSE b PASSPORT b PHOTO ID
need not be revealed V520730847354 MI 05/09/2020 V520461744734 MI 09/22/2019
ID# STATE EXPIRATION DATE (MM/DD/YYYY) ID# STATE EXPIRATION DATE (MM/DD/YYYY)
if you do not wish to
have it considered as ESCO RETAIL HOME MAKER
a basis for repaying EMPLOYER EMPLOYER
this obligation. 300000
ANNUAL INCOME FROM ALL SOURCES* ANNUAL INCOME FROM ALL SOURCES*
(Do not complete if this is an application for individual unsecured credit) (Do not complete if this is an application for individual unsecured credit)
b
■ MARRIED b SEPARATED b UNMARRIED (includes single, divorced, widowed) b
■ MARRIED b SEPARATED b UNMARRIED (includes single, divorced, widowed)
TRUST
Please see page 4 for NAME OF TRUST
required information.
TAX ID / EIN OF TRUST STATE WHERE ORGANIZED
ADDRESS OF TRUST PHONE
Type of Trust: b Revocable b Irrevocable
GRANTOR(S) OF TRUST*
TRUSTEE(S) OF TRUST*
*COMPLETE REQUIRED INFORMATION ON TRUST ADDENDUM (PAGE 5) FOR ALL GRANTOR(S)/TRUSTEE(S).
BUSINESS
Name of Authorized Signer(s) and Title(s):_ __________________________________________________________________________________________________________________
Entity
Please see page 4 for
Business Entity: b Corporation b Limited Liability Company b Limited Liability Partnership b General Partnership
required information.
b Limited Partnership b Other (Specify Type)
LEGAL NAME OF ENTITY FICTITIOUS NAME(S) (D/B/A) (IF APPLICABLE)
PRIMARY PHYSICAL ADDRESS (P.O. NOT ACCEPTABLE) STATE/COUNTRY OF ORGANIZATION
United States Entity? b Yes b No Year Organized: Tax ID/EIN:
TYPE/DESCRIPTION OF PRINCIPAL BUSINESS PHONE
NPA 102715
Non-Purpose Application
Page 2 of 6
2 APPLICANT BACKGROUND INFORMATION (Applies to all Individual, Business entity and Trust applicants)
4 YEARS
How long have you been a client of your investment advisor? _ ________________________________________________________________________
PRESIDENT
What is your occupation? Applicant_______________________________________ HOMEMAKER
Co-Applicant ___________________________________________
3MM
Please provide an estimate of your net worth_ _______________________________________________________________________________________
2MM
What is the value of all your accounts with your investment advisor(s)?_________________________________________________________________
EMPLOYMENT INCOME
Briefly describe how you accumulated your wealth_ __________________________________________________________________________________
3 Notice of Loan Document Representations
If your loan is approved, we will require you to provide certain representations as to your current financial and legal status, to include, but not
be limited to, that (i) you have no pending suits or legal actions against you that could have a material adverse effect on your financial condition;
(ii) you have no past due tax obligations; and (iii) you have not received debt forgiveness from a lending institution within the past 3 years.
4 Line of Credit / Letter of Credit REQUEST INFORMATION
Line of Credit
b
■ NEW b MODIFICATION
250000
REQUESTED AMOUNT $______________________________________________________________________________________ LOAN REPAYMENT IS INTEREST ONLY
Loan Type:
b
■ REVOLVING DEMAND LINE OF CREDIT WITH A FLOATING RATE interest Rate: b 2.5
■ 30 Day Libor + ___________ Or b Prime Rate + ____________
Disclosure B
**The term “margin
stock” includes stocks b Non-Revolving Demand Line of Credit with a Fixed Rate Period
that are registered on Fixed Rate Period b 1 Year b 2 Years b 3 Years b 5 Years Fixed interest Rate* _____________________________
a national securities
exchange or any over- Floating Rate Period (Required Information): b 30 Day Libor + ___________ b Prime Rate + __________________________________
the-counter security *Fixed rate is effective if line is closed within 30 days of application subject both to lender’s timely receipt and to lender’s acceptance of the application.
designated for trading
in the National Market
System; debt securities ADDITIONAL CASH FLOW
purpose / use of funds: __________________________________________________________________________________________________________
(bonds); debt
securities (bonds)
Will any part of the loan/line be used to purchase or carry margin stock, or to refinance existing debt which was used to purchase
that are convertible
into margin stock and or carry margin stock?** b Yes b No
■ Amount $______________________
shares of most
mutual funds. Are all or any funds going to pay off existing loans? b Yes b
■ No If yes: Approximate payoff amount $_______________________
Name of Lender:____________________________________________________________ Loan Number: _ ______________________________________
Do you have any other credit facilities with this lender? b Yes b
■ No If Yes: Please describe___________________________________
_______________________________________________________________________________________________________________________________
Letter of Credit
TOTAL AMOUNT: $ ______________________________________ (Please contact Bank for required information)
5 COLLATERAL INFORMATION (Please provide a copy of the Brokerage Statement(s) for the pledged account(s) for this request.)
Accounts
VINCE AND KAREN VENEZIA JOINT ACCOUNT/ LPL FINANCIAL
Account Name Registration / Custodian
If you are pledging
TBD TBD
Account Number Account Number
additional collateral
accounts in another
name, please complete
Are there any regular monthly distributions from these accounts? b Yes b
■ No If yes, amount $_ _______________
the additional Are any of these accounts pledged to another loan? b Yes b No
■
account application
supplement If name on the collateral account is different than the applicant(s), please provide the following:
on page 6. b Individual b Business Entity: b Corporation b Partnership b Sole Proprietor b LLC b Trust: b Revocable b Irrevocable
Name of Individual, Business Entity, or Trust Relationship to Applicant
SSN / Tax ID / EIN
Address
NPA 102715
Non-Purpose Application
Page 3 of 6
6 PROVIDE INSTRUCTIONS TO RECEIVE LOAN DISBURSEMENTs
Select applicable box: b
■ Wire Instructions (Same day availability of funds) b ACH Instructions (24–96 hours for funds to be available)
■
CHASE BANK
Bank
072000326 VENEZIA CHECKING 709021679
Routing ABA # Account Name Account Number
Please ensure that you provide the correct routing ABA number depending on whether these are for ACH instructions or wire instructions.
7 Provide ACH instructions For monthly interest Loan payments
CHASE BANK
Bank
072000326 VENEZIA CHECKING 709021679
Routing ABA # Account Name Account Number
8 ACKNOWLEDGEMENT AND AGREEMENT
b Check box and sign below if this is an application for joint credit. Applicant and co-applicant and/or Guarantor(s) agree that
■
we intend to apply for joint credit.
Disclosure C representations and warranties
This Loan Application is provided to TriState Capital Bank (Lender) for its review of my/our creditworthiness, and Lender can rely on its contents. I/We hereby warrant
to Lender that this Loan Application is complete and correct as of the date prepared and that I/we will promptly inform the Lender of any material changes in the
information provided. I/We authorize Lender to make whatever inquiries about me/us Lender deems appropriate, including for the purposes of verifying or checking
on any information given and evaluating my/our credit and reverifying my/our credit from time to time, including obtaining credit bureau reports and contacting
my/our employer(s). I/We authorize Lender to provide credit information about its credit experience with me/us to other creditors and credit reporting agencies in
accordance with the Fair Credit Reporting Act or similar laws. I/we acknowledge and agree that Lender may share and/or request follow-up information regarding this
loan application with/from my financial advisory firm or directly with/from me/us. The undersigned acknowledges and agrees that the Lender is not obligated to grant
credit to the undersigned or any other party, and the Lender may retain this Loan Application even if the credit is not granted.
FEE ARRANGEMENTS
I/we understand that Lender is not an affiliated entity with either my financial advisory firm (“Firm”) or the securities intermediary of my assets (the “Custodian”, which
may or may not be the Firm), and that neither the Firm nor the Custodian are or will extend credit to me/us pursuant to this application. I/we further acknowledge that,
if Lender grants credit to me/us pursuant to this application, the Firm and/or Custodian may receive a fee for its referral of me/us to Lender, which may be reflected in
my/our loan pricing.
Do you have a freeze on your credit report? Applicant: b Yes b
■ No Co-Applicant: b Yes b
■ No
Guarantor: b Yes b No Guarantor: b Yes b No
Applicant /Guarantor/ Trustee / Authorized Signer’s Signature Date
Co-Applicant / Guarantor/ Trustee / Authorized Signer’s Signature Date
Co-Applicant / Guarantor/ Trustee / Authorized Signer’s Signature Date
9 INTERVIEWER
BRIAN KRUKIEL (817) 717-3812
INTERVIEWER’S NAME (Print or type) INTERVIEWER’S TELEPHONE
If application was
taken by telephone,
2435 East Southlake Boulevard Suite 120 SUTHLAKE, TX 76092
Interviewer confirms INTERVIEWER’S BUSINESS ADDRESS
the applicable
[email protected]disclosures (A, B and
Email Address
C) were read to the
applicant(s). 09/18/2016
INTERVIEWER’S SIGNATURE DATE
Bank Use Only
Date Application Received by TriState Capital Bank Bank Representative Name
NPA 102715
Non-Purpose Application
Page 4 of 6
10 REQUIRED INFORMATION (To be collected by the Interviewer)
All Borrowers, Co-Borrowers and Eligible Guarantors must provide the documents as provided below (in most instances, a high-
Please check quality photocopy will be acceptable) as applicable. Please check the applicable box below.
all collected
information.
For All Collateral Accounts
b Copy of most recent collateral account statement(s).
For Individuals *Copy of identification documentation for applicant and/or co-applicant may not be required based on
master agreement between TriState Capital Bank and your Financial Advisory Firm.
b
(1) Current state-issued Driver’s License or other form of state-issued identification, with a photograph, OR (2) valid Passport,
with a photograph, together with documentary proof of current residence, such as a current utility bill.
For Sole Proprietors
b
The information identified above under “FOR INDIVIDUALS” for the owner of the Sole Proprietorship, and if the Sole
Proprietorship conducts business under a fictitious name, evidence that such fictitious name has been registered with the
state in which the business is conducted.
For Corporations
b Certified copy of properly filed Articles of Incorporation and all amendments thereto.
b Bylaws certified by the Secretary of the Corporation.
For Limited Liability Company
b Articles or Certificate of Organization issued by state of formation including all amendments thereto.
b Operating Agreement and all amendments thereto.
For Limited Liability Partnership
b Articles or Certificate of Organization issued by state of formation including all amendments thereto.
b Partnership Agreement and all amendments thereto.
For Limited Partnership
b Articles or Certificate of Organization issued by state of formation including all amendments thereto.
b Limited Partnership Agreement and all amendments thereto.
b If General Partner is an entity, provide documents specific for such entity type as specified above or below.
For General Partnership
b The documentation identified above for each individual or entity General Partner.
b Partnership Agreement and all amendments thereto.
For Trusts: Revocable Trust/Irrevocable Trust
b Trust Agreement and all amendments thereto.
b Complete Trust Addendum (page 5) if applicable for all Trustee(s) and for Revocable Trusts only, all Grantor(s).
b
Death Certificate if Grantor is deceased. Note that if deceased, we may be unable to approve loan without additional
underwriting and/or an IRS Estate Tax closing letter.
b
Copy of State or Government issued ID for Trustees and Grantors for Revocable Trusts if the Trust is an applicant
or co-applicant.
For Attorney in Fact (by Power of Attorney) (“POA”)
b Provide the information requested above for each principal under the POA.
NPA 102715
Non-Purpose Application
Page 5 of 6
TRUST
ADDENDUM*
HE BELOW MUST BE COMPLETED FOR ALL APPLICABLE GRANTORS(S) AND/OR TRUSTEE(S) IF THE TRUST IS THE APPLICANT OR
T
11 CO-APPLICANT. THE BELOW IS NOT REQUIRED IF THE TRUST IS ONLY THE PLEDGOR.
Grantor(s)/Trustee(s):
b Grantor b Trustee
Name
Address
SSN / EIN Date of birth (MM/DD/YYYY)
Identification for Individuals: b Drivers License b State-Issued ID b Passport
Issue Date ID# State Expiration date (MM/DD/YYYY)
Grantor(s)/Trustee(s):
b Grantor b Trustee
Name
Address
SSN / EIN Date of birth (MM/DD/YYYY)
Identification for Individuals: b Drivers License b State-Issued ID b Passport
Issue Date ID# State Expiration date (MM/DD/YYYY)
Grantor(s)/Trustee(s):
b Grantor b Trustee
Name
Address
SSN / EIN Date of birth (MM/DD/YYYY)
Identification for Individuals: b Drivers License b State-Issued ID b Passport
Issue Date ID# State Expiration date (MM/DD/YYYY)
Grantor(s)/Trustee(s):
b Grantor b Trustee
Name
Address
SSN / EIN Date of birth (MM/DD/YYYY)
Identification for Individuals: b Drivers License b State-Issued ID b Passport
Issue Date ID# State Expiration date (MM/DD/YYYY)
NPA 102715
Non-Purpose Application
Page 6 of 6
Additional Collateral Accounts
APPLICATION
SUPPLEMENT
12 SUPPLEMENTAL COLLATERAL INFORMATION (In addition to those listed on page 2 of application)
Account
Account Name Registration / Custodian
Account Number Account Number
Are there any regular monthly distributions from these accounts? b Yes b No If yes, amount $_ _______________
Are any of these accounts pledged to another loan? b Yes b No
If name on the collateral account is different than the applicant(s), please provide the following:
b Individual b Business Entity: b Corporation b Partnership b Sole Proprietor b LLC b Trust: b Revocable b Irrevocable
Name of Individual, Business Entity, or Trust Relationship to Applicant
SSN / Tax ID / EIN
Address
Account
Account Name Registration / Custodian
Account Number Account Number
Are there any regular monthly distributions from these accounts? b Yes b No If yes, amount $_ _______________
Are any of these accounts pledged to another loan? b Yes b No
If name on the collateral account is different than the applicant(s), please provide the following:
b Individual b Business Entity: b Corporation b Partnership b Sole Proprietor b LLC b Trust: b Revocable b Irrevocable
Name of Individual, Business Entity, or Trust Relationship to Applicant
SSN / Tax ID / EIN
Address
Account
Account Name Registration / Custodian
Account Number Account Number
Are there any regular monthly distributions from these accounts? b Yes b No If yes, amount $_ _______________
Are any of these accounts pledged to another loan? b Yes b No
If name on the collateral account is different than the applicant(s), please provide the following:
b Individual b Business Entity: b Corporation b Partnership b Sole Proprietor b LLC b Trust: b Revocable b Irrevocable
Name of Individual, Business Entity, or Trust Relationship to Applicant
SSN / Tax ID / EIN
Address
Account
Account Name Registration / Custodian
Account Number Account Number
Are there any regular monthly distributions from these accounts? b Yes b No If yes, amount $_ _______________
Are any of these accounts pledged to another loan? b Yes b No
If name on the collateral account is different than the applicant(s), please provide the following:
b Individual b Business Entity: b Corporation b Partnership b Sole Proprietor b LLC b Trust: b Revocable b Irrevocable
Name of Individual, Business Entity, or Trust Relationship to Applicant
SSN / Tax ID / EIN
Address
NPA 102715
