Date of Call Info / Application Sent (circle one)

1) Potential Borrower :

Address :

County of Residence :

Phone Number / email:

2) Person with disabilities (if different) Name :

Age Disability

Address :

County of Residence :

Phone Number / email :

AT needed Estimated Cost

3) Name of Caller (if different)

Address :

Phone Number / email :

How would you like to receive the information/application? Standard print Large print

By email Other

How Did You Hear About PATF?

Application Received Items need, if incomplete

Amount of Loan Request Estimated Monthly Payment

Application Complete Faxed to Bank

Guarantee Requested Yes No (attach copy of reply from Bank)

Board Review – Date / Results

Notified FUNB (attach copy)

Withdrawn / Denied – (reasons)

Borrower Notified (attach copy)