Golden Plains Credit Union - Financial Hardship Form

* - Indicates required field

Member Name

List all borrowers on note

Loan Account #

SSN

Contact Method (please list your phone # or email address)

I am declaring a financial hardship for the following reason(s)

Loss of Employment
Other

If other, please explain

Date of Loss of Employment (if applicable)

If loss of job is temporary, when do you expect to return?

Are you receiving any source of income?

YesNo

If yes, please provide income source and amount

Are you actively looking for employment?

YesNo

If yes, please provide a list of companies you have applied at

Signature

Date

Prove you're not a robot.*