REVOLVING CREDIT
Each applicant may apply for individual or joint credit regardless of marital status. This application is for:
□ Individual Credit – complete applicant information.
□ Joint Credit with Spouse as Joint Applicant – complete applicant and co-applicant information.
□ Joint Credit with Non-Spouse as Joint Applicant – complete applicant and co- applicant information.
We intend to apply for joint credit:
_______________________________________     ______________________________________
Applicant Sign Here 

               Co-Applicant Sign Here

DEALER USE ONLY
Applicant’s identification was verified via viewing an unexpired driver’s license unless one of the following 
is checked: Unexpired:   ___ State Issued ID Card     ___ Passport     ___Social Security Card
Co-Applicant’s  identification  was  verified  via  viewing  an  unexpired  driver’s  license  unless  one  of  the 
following is checked: Unexpired:   ___ State Issued ID Card    ___ Passport     ___Social Security Card

Verified By:  _________________________________________________________________________

Dealer # _________________Initial Sale $__________________Down Payment $_____
In this Agreement “you” and “your” refer to all persons applying for credit and “we”, “us”, 
and “our” refer to Dealer and its assigns. 

CUSTOMER CREDIT APPLICATION
APPLICANT INFORMATION   (Please Type or Print Clearly)

Check if you are NOT a US Citizen           □     No. of Dependents
Social Security Number             Date of Birth           E-mail Address           

First Name                                     Middle                         Last Name

Residence Address (No PO Box allowed)                                     Time at Residence

                                                                                                           Yrs.             Mos.
City                                                              State                                      Zip

□ Own                              Monthly Mortgage Payment                   Home Value                                      
□ Rent                               $                                                         $                                                        
Home Phone Number                Cell Phone Number                    Work Phone Number

             /                /                            /                /                                 /                /
Previous Employer          Occupation                      Gross Monthly Salary   Length of Employment

                                                                             $                                           Yrs.         Mos.               
Alimony, child support or separate maintenance income need not be revealed if you do not wish to 
have it considered as a basis for repaying this obligation.
Other Income                    Source                                               Monthly Amount

$                                                                                               $

PERSONAL REFERENCE   (Not Living With You)

Name

Relationship                                                                 Phone Number
                                                                                                   /                /

CO-APPLICANT INFORMATION   (For Joint Applications Only)

Check if you are NOT a US Citizen           □     No. of Dependents 
Social Security Number             Date of Birth           E-mail Address

First Name                                     Middle                         Last Name

Residence Address (No PO Box allowed)                                     Time at Residence 

                                                                                                            Yrs.             Mos.
City                                                              State                                      Zip

Home Phone Number                Cell Phone Number                    Work Phone Number

             /                /                            /             /                                     /             /
Present Employer           Occupation                      Gross Monthly Salary   Length of Employment

                                                                             $                                           Yrs.        Mos.
Alimony, child support or separate maintenance income need not be revealed if you do not wish to 
have it considered as a basis for repaying this obligation.
Other Income                    Source                                               Monthly Amount

$                                                                                               $
By signing this application: 1) you warrant all information you provide is true and complete; 2) you authorize 
Dealer to assign this application to Culligan Finance Company (a division of Aqua Finance, Inc.) or its assigns; 
3)  you  authorize  a  full  investigation  and  release  of  any  records  from  any  source,  including  credit  bureau 
reports, to check the accuracy of information on this application; and 4) you consent to receiving autodialed 
message calls from us or our agents on your wireless phone. You have a continuing duty to keep us informed 
if any information on this application changes. By completing and signing this application you understand that 
you have requested that we open a revolving credit account which allows you to make credit purchases on 
account as evidenced by a revolving credit sales slip, and you agree to all the terms and conditions of this 
Revolving Credit Agreement. By your signature you acknowledge that you have received and read all the 
terms of this Agreement before making any purchases on the account.
CFC-AFI-500-RCA   1-1-2016   232726
CFC-AFI-500-RCA   1-1-2016   232726

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Annual Percentage

Rate (APR)

for Purchases 

IF THIS IS A JOINT ACCOUNT YOU UNDERSTAND THAT EACH APPLICANT HAS THE RIGHT TO USE THE 
ACCOUNT TO THE CREDIT LIMIT AND THAT CO-APPLICANTS ARE JOINTLY AND SEVERALLY LIABLE 
FOR ALL PURCHASES ON THE ACCOUNT.  See State Notices for important information regarding this 
credit application and agreement. No agreement exists between us until this application is approved.
SOCIAL  SECURITY  NUMBER/TAXPAYER  IDENTIFICATION  NUMBER:    Under  penalties  of  perjury,  I  certify  that:  1)
The number shown on Page 1 of this Credit Application is my correct taxpayer identification number (or I am waiting for a 
number to  be issued to me),  2) I am not subject to backup withholding because: (a) I am exempt from backup withholding; 
or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of 
a failure to report all interest or dividends; or (c) the IRS has notified me that I am no longer subject to backup withholding; 
and 3) I am a U.S. person (including a U.S. resident alien). Certification Instructions: Cross out item 2 above if you have 
been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest 
and dividends on your tax return.  Cross out item 3 and complete a W-8 BEN if you qualify and are not a U. S. Person.
The Internal Revenue Service does not require your consent to any provision of this document other 
than the certification required to avoid backup withholding.
Your  Minimum  Monthly  Payment  will  be  between  2%  and  5%  of  the  “Highest  Monthly  Charge” 
balance since your Monthly Charge Balance was zero (less any Special Payment Plans) as will be 
shown on your billing statement, rounded to the next highest dollar, or $15, whichever is greater.  If 
you are a participant in specified Promotion Plans, your Minimum Monthly Payment will be between 
1%  (for  first  12  months)  and  2%  (thereafter)  of  the  “Highest  Monthly  Charge”  balance  or  $15, 
whichever is greater.  A finance charge will be computed on your outstanding balance each month.
DO  NOT  SIGN  BELOW  UNLESS  MERCHANT  HAS  PROVIDED  THE  ATTACHED  DISCLOSURES  AND 
TERMS. BY YOUR SIGNATURE BELOW YOU ACKNOWLEDGE RECEIPT OF THE ATTACHED REVOLVING 
CREDIT AGREEMENT.

IMPORTANT INFORMATION ABOUT YOUR ACCOUNT

KEEP THIS INFORMATION FOR YOUR RECORD

*Maximum Non-Introductory State APR Rates

REVOLVING CREDIT AGREEMENT AND DISCLOSURE STATEMENT

Dealer may assign all rights under this Agreement and any credit sale made pursuant to it (as evidenced by a revolving 

credit sales slip) to Culligan Finance Company (a division of Aqua Finance, Inc.) (“CFC”) and to CFC’s further assigns. 

***Not  all  offers  will  contain  introductory  rates.  If  not  otherwise 

specified on Revolving Credit Sales Slip or Promo Addendum, then 

your APR is the maximum non-introductory state APR in table, below.

Interest Rates and Interest Charges

Introductory rates between 0% and 

9.9%, ranging from 6 months to 12 

months.***  Non-introductory rates 

between 5.9% and 17.99%.

All rates are based on the specific 

promotion or your credit worthiness, and 

dealer participation. (Maximum APR 

Varies By State. See table below *)

21% (see table below for applicability 

in your state**) This APR may be 

applied to your account if you make a 

late payment.  

How Long Will the Penalty Rate 

Apply?:  The Penalty APR may 

remain in effect indefinitely.

Interest Charges begin on the date a 

purchase is posted to your account, 

except in states requiring a grace 

period, in which case your due date 

is at least 25 days after the close 

of each billing cycle and we will not 

charge you interest if you pay your 

entire balance by the due date.

If you are charged interest, the charge 

will be no less than $0.50.

To learn more about factors to consider 

when applying for or using a credit 

card, visit the Consumer Financial 

Protection Bureau’s website at 

http://www.consumerfinance.gov/learnmore.

Fees Vary By State

Up to $35 See Paragraph 11 of Agreement

Up to $35 See Paragraph 12 of Agreement

Penalty APR 

and When it Applies**

Paying Interest 

Minimum Interest Charge

For Credit Card Tips from 

the Consumer Financial 

Protection Bureau

Fees 

Penalty Fees

•Late Payment 

•Returned Payment 

17%

Arkansas

17.99% All other states

** The penalty APR rate does not apply in the following states: Arkansas, Colorado, 

Connecticut,  Delaware,  Florida,  Illinois,  Kansas,  Louisiana,  Maine,  Maryland, 

Massachusetts,  Michigan,  Minnesota,  Missouri,  Nebraska,  North  Carolina, 

Oklahoma, Pennsylvania, Rhode Island, South Carolina, Texas, and Wyoming.

1. GENERAL:  If your credit application is approved and we open a revolving credit account for you, 

you may purchase household goods and services on credit from the dealer where you opened your 

account.  Purchases  are  pursuant  to  a  revolving  credit  sales  slip  and  you  agree  that  all  sales  are 

subject to the terms of this Agreement. 

cent. Any Daily Balance less than zero will be treated as zero. A minimum INTEREST CHARGE 

of no less than $0.50 is added to your account in any billing cycle your account is subject to an 

INTEREST CHARGE, except in states where prohibited by law. The grace period is 25 days in 

Louisiana, Maine, Maryland, Massachusetts, Mississippi, North Carolina, and Virginia and 30 days 

in Nebraska & Vermont on new purchases where your account balance is $0 or you have paid your 

previous balance due in full by the end of the billing cycle.  

9.  DEFAULT:    You  are  in  default  if:  (a)  you  fail  to  make  a  required  payment  when  due  on  two 

occasions in any 12 month period; (b) you fail to observe or perform any of the other covenants or 

duties contained in this Agreement if the failure materially impairs the condition, value or protection 

of our right in any Collateral, or materially impairs your ability to pay any amounts on your billing 

statement when due. You will receive a Notice of Right to Cure in the following states: Colorado, 

Iowa, Kansas, Maine, Massachusetts, Missouri, Nebraska, Pennsylvania, and Wisconsin. If you fail 

to cure within the time allowed in your notice or within 30 days if you live in a state with no notice 

requirement, we may accelerate your balance.

10. SPECIAL CREDIT PROMOTION PLANS: We may occasionally offer special credit promotion 

2.  PROMISE  TO  PAY:    You  agree  to  pay  for  all  purchases  made  on  your  account,  INTEREST 

CHARGES, and other applicable charges or fees under this Agreement incurred by you or anyone 

plans for you to participate in at your option.

you  authorize  or  permit  to  use  your  account.  If  this  account  is  a  joint  account,  each  joint  account 

11. LATE FEE:  If your payment is more than 10 days late (15 days in ME, MA, ID or SD and 30 

holder agrees to pay, and all account holders are jointly and severally responsible for all amounts 

days in NC), you may be charged a late fee up to the amount indicated below for your state of 

owed on the account. If your account is referred for collections to an attorney who is not our salaried 

residence.  The late fee will be added to your account balance.

employee, you agree to pay reasonable attorney fees and reasonable collection costs to the extent 

allowed by law in your state. If your state does not allow attorney fees (IA, ME, OH, and WI), you 

agree to pay any statutory attorney fees and costs that may be awarded to us by a court of law. 

KS & MO if payment due is less than $25

AK, AR, CA, FL, KS, MO, MT, NJ, NC, OH, RI, SD, TN  

CO, IN, IA, MS, NV, NH, NY, ND, OR, VT, WA, WI

3. CREDIT LIMIT:  We set a credit limit on your account which we may modify at any time for any 

reason not prohibited by law. You may not charge purchases if it causes you to exceed your credit 

GA

limit unless we allow such purchases. You agree to pay all amounts over your credit limit.

4. BILLING STATEMENT:  We will mail you a statement each month you have an account balance 

greater than $1.00 at the address we have in our records. This statement will show credit purchases, 

late  charges,  NSF  fees,  previous  balance,  new  balance,  payments  received,  credits,  INTEREST 

CHARGES, total minimum payment due, and payment due date.

5.  MINIMUM  MONTHLY  PAYMENT:    All  payments,  except  disputed  payments,  must  be  mailed 

or delivered to the Payment Processing Center address shown on your monthly billing statement. 

All payments must be made by electronic fund transfer, check or money order. Do not send cash. 

Cash or other nonconforming methods of payment may be rejected. We may accept partial or late 

payments or checks marked “payment in full” or other restrictive endorsement without losing our right 

to receive the full amount owed. Your billing statement will include requirements for you to follow in 

making payments. Disputed payments, including those which indicate that the payment constitutes 

“payment in full” of the amount owed, must be mailed or delivered to the Customer Service address 

listed below. You agree to pay us at least the Total Minimum Monthly Payment reflected on your 

statement. You may pay more than the Total Minimum Monthly Payment and you may pay the entire 

amount due at any time.  The Total Minimum Monthly Payment Due shown on your billing statement 

will be the sum of the Minimum Monthly Payment plus all past due amounts, late fees, and other 

charges. The Minimum Monthly Payment is calculated at the end of the first month in which you make 

a  purchase,  and  will  be  calculated  each  month  in  which  you  make  an  additional  purchase.    Your 

Minimum Monthly Payments will be between 2% and 5% of the “Highest Monthly Charge” balance 

MN -$7.80 maximum

KY & WY ($10 minimum); 

AL, ID & MI ($15 minimum);

HI, NE, VA

UT

OK ($5 minimum)

SC, TX, D.C.

AZ, CT, IL, LA, MD, ME, PA

NM

MA

5% of payment due

5% of payment due;  $35 maximum*

5% of payment due; $30 maximum*

     5% of payment due;            $20 maximum

5% of payment due; $15 maximum

5% of payment due; $10 maximum

5% of payment due; $5 maximum

10% of payment due; $10 maximum

*($25 maximum-first occurrence in more than 6 months.)

12. RETURNED PAYMENT / NSF FEE:  If any payment instrument or method is dishonored by 

your bank or the drawee, you agree to pay an NSF fee up to the amount indicated below for your 

state of residence.  No NSF fee will be charged if your state of residence is DE, MD, NE or WY.  If 

required by your state, you will receive a notice with instructions about the NSF service or collection 

fees, and if you fail to pay the fee we will add it to your account balance.  We are not required to 

present payment instruments more than once to the drawee for payment. This fee will be added 

to your account balance. 

since your Monthly Charge Balance was zero (or if you participate in specified Promotion Plans, Your 

MA, ME, AZ (greater of $10 or bank fee)

Minimum Monthly Payments will be between 1% and 2% of the “Highest Monthly Charge” balance 

since your Monthly Charge Balance was zero), less any Special Payment Plans as shown on your 

billing statement rounded to the next higher dollar, or $15, whichever is greater, unless your account 

balance is less than $15 in which case the Minimum Monthly Payment will be equal to the account 

CA, MS, MO

CT, D.C., ID, IA, NJ, NY, OH, PA, UT, VT

balance. You agree that any payment may be returned if your check is (i) not drawn in U.S. dollars 

AR, CO, FL, IL, IN, KY, LA, MI, MN, NV, NH, NM, NC, OK,  RI, TX, WI 

$5

$10

$15

$25

$10

$15

$20

$25

$30*

$35*

on funds on deposit in the U.S.; (ii) missing a signature; (iii) drawn with different numeric and written 

amounts; (iv) contains a restrictive endorsement; (v) postdated; or (vi) not paid on presentment.  If 

you do not make a Total Minimum Monthly Payment within 60 days of its due date, we may apply the 

Penalty APR to your account, if allowed by the state of your residence.  We will give you advanced 

notice of the date the Penalty APR is effective.  The Penalty APR may remain in effect indefinitely, 

unless you make the first six consecutive Total Minimum Monthly Payments when due following the 

effective date of the application of the Penalty APR to your account.

6. ELECTRONIC FUND TRANSFER:  When you provide a check, you authorize us either to use 

information  from  your  check  to  make  a  one-time  electronic  fund  transfer  from  your  account  or  to 

process the transaction as a check.  When we use your check to make an electronic fund transfer, 

funds may be withdrawn from your account as soon as the same day we receive your payment, and 

you may not receive your check back from your financial institution. If there are insufficient funds in 

your account you authorize us to charge an NSF Fee as indicated below and collect that amount 

through an electronic fund transfer from your account.

AL, AK, GA, HI, KS, MT, SC, SD, TN

ND, OR, VA, WA

*($25 maximum-first occurrence in more than 6 months.)  

13.  ACCOUNT  INFORMATION:    You  authorize  us  to  furnish  information  about  your  account  to 

credit reporting agencies and anyone else who may lawfully receive such information. On request, 

you agree to promptly provide us with accurate and updated financial and employment information. 

You agree to give us prompt notice of any change in your name, address, and telephone numbers. 

Where allowed by law, you authorize the Department of Motor Vehicles to release your address if 

it becomes necessary to locate you.

14. CHANGE IN TERMS:  We may change the terms of this Agreement, as permitted by law, at 

any time. You will be notified of changes in accordance with applicable state and federal law, but in 

the event your state does not specify a time period, you will be notified at least 45 days in advance 

of any such changes, and such notice will be sent to your current address as shown on our records 

for your account. We count the days from the date we mail the notification. 

15.  CREDIT  INVESTIGATION:    You  agree  we  may  investigate  your  credit,  employment,  and 

financial status. You authorize us to obtain a credit report and any other information about your 

creditworthiness  in  connection  with  processing  your  application  for  credit,  and  subsequently  in 

connection with any extension of credit, request to increase credit limits, or any renewal or update 

of your account, or to take collection action on the account, or to investigate disputes regarding 

the account. At your request, we will inform you if such reports were ordered, and the names of 

the credit bureaus that provided reports. You authorize the Department of Defense and its various 

departments and commands to verify your social security number or other identifier and disclose 

your  home  address  to  the  authorized  holder  of  this  Agreement  for  purposes  of  performing  or 

enforcing  the  terms  of  this  Agreement.  You  authorize  any  past  or  present  employer  to  confirm 

employment  or  communicate  with  us  regarding  your  indebtedness  to  us  if  you  fail  to  meet  the 

terms and conditions of this Agreement. We use information furnished solely in connection with 

performing or enforcing the terms of this Agreement. 

                                                                                                                        /           /
Applicant Signature                                                                             Date

                                                                                                                        /           /
Applicant Drivers Lic. No.                              State                                 Expiration Date

                                                                                                                        /           /
Joint Applicant Signature                                                                    Date

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Joint Applicant Drivers Lic. No.                     State                                   Expiration Date
NOTICE TO WISCONSIN APPLICANTS: No provision of a marital property agreement, a unilateral statement under 
Wis. Stats. §766.59, or a court decree under Wis. Stats. §766.70 adversely affect the interest of the creditor unless the 
creditor is furnished a copy of the decree, agreement, statement, or has actual knowledge of the adverse provision prior 
to the time credit is granted. You must supply us with your spouse’s name and address in the Spouse/Joint Applicant 
section above so we can give notice of this credit transaction by mailing a copy of this application.  If you are married, 
you agree that this obligation is incurred in the interest of marriage or family. 
Applicant Signature:_________________________________________________________________
CREDIT REPORT NOTICE: We may request a credit report for any legitimate purpose associated with 
your application for credit, extending credit, modifying the terms of your credit agreement, or collection 
on your account. On your request we will inform you if such a report was ordered and will give you the 
name and address of the credit reporting agency that furnished the report.
NOTICE: The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit 
applicants on the basis of race, color, religion, national origin, sex, 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 
the law concerning this creditor is the Federal Trade Commission.
Delaware residents: Service charges not in excess of those permitted by law will be charged on 
the outstanding balances from month to month.
Maryland residents: Finance charges will be made in amounts or at rates not in excess of those 
permitted by law.
ASSIGNMENT:  Should Culligan Finance Company (a division of Aqua Finance, Inc.) (“CFC”) acquire 
your  account  as  a  result  of  your  credit  application,  CFC  may  further  assign  your  credit  transaction.  
If  your  transaction  is  assigned  to  Connexus  Credit  Union  (“Connexus”)  you  will  be  required  to 
become a member.  Membership will be granted through joining the nonprofit Connexus Association 
(“Association”), a 501(c)(3) entity established to conduct charitable giving throughout the United States.  
In that event, and by signing this application, you agree to join Connexus and the Association, and the 
terms of membership in each organization.

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AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS

By  signing  below,  I  hereby  authorize  the  initiation  of  a  periodic  deduction  from  my  account  at  the  financial 
institution  named  below  through  the  ACH  system  and  authorize  said  institution  to  debit  my  account  for  the 
amount and at the frequency set forth below.  I acknowledge that this request does not violate the provisions of 
United States law as it applies to ACH transactions.  I understand I have a right to stop this au tomatic payment 
by notifying either the institution named below or CFC, in writing, at least three (3) business days prior to the day 
my account is scheduled to be charged and that there may be a fee for that service.  Further I agree that CFC 
will require written confirmation of an oral stop-payment order within fourteen (14) days.  This will be a permanent 
stop payment on this preauthorized payment.  I may, however, establish a new preauthorized payment from the 
same financial institution or company in the future.  I also authorize adjustment entries in the event of erroneous 
transactions on my account.  I agree to hold CFC harmless for any expenses, including fees, incurred as a result 
of its inability to process a scheduled preauthorized withdrawal due to:  my having supplied incorrect information, 
its having acted on a stop payment order, or there being insufficient funds in the account I have indicated.

Monthly Payment_________________________

Day of Month for Withdrawal ____________ Month First Payment is to be Drawn ______________

Bank Name ______________________________________________________________________

Bank  Address_____________________________________________________________________
If not filled in, you are authorized to deduct the payment amount set forth in my Revolving Credit Sales Slip for the account listed on my voided check.
IMPORTANT: PLEASE ATTACH A VOIDED CHECK WITH CORRECT ENCODING INFORMATION
Type of Account: □ Checking □ Savings
Bank Routing Number _____________________ Depositor Account Number ______________

X______________________________________  X _____________________________________
Signature of Depositor                                            (if joint account, both must sign)
□ I would like to receive my monthly account statements by email and have access to pay my bill online.

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How We Will Calculate Your Balance: We use a method called the “Daily 

Balance (including new purchases).”  See your account Agreement for more 

details.

Loss of Introductory APR: We may end your introductory APR and apply the 

Penalty APR if you make a late payment.

7. PREPAYMENT:  You may pay your entire account balance at any time without penalty.  If you do 

not pay the entire balance in full, you must make a minimum payment each month by the payment 

due date that appears on your billing statement. Under federal law, we are not required to refund any 

Billing Rights: Information on your rights to dispute transactions and how to 

amounts less than $1.00.

exercise those rights is provided in your account agreement.

This  information  is  accurate  on  the  date  of  your  application  and  initial 

purchase.  If any of this information changes you will be notified at least 

45 days prior to any change and how to contact us regarding any change.  

All terms are subject to change.

8. INTEREST CHARGE:  INTEREST CHARGES begin the date a purchase is posted to your account 

and accrue as long as your account has a balance, except in states with a mandatory grace period. 

The INTEREST CHARGE is computed by applying a daily periodic rate of between 0% and .02712% 

(corresponding to an APR of 9.9%) for an Introductory APR, or between .01616% (corresponding to 

an APR of 5.9%) and .04929% (corresponding to an APR of 17.99%) for a Non-Introductory APR, to 

the daily balance. The daily balance is calculated by taking the beginning balance in the account each 

day, adding any new purchases, and subtracting any unpaid interest or other finance charges and 

any payments and credits. The INTEREST CHARGE is calculated by (i) taking each daily balance, 

(ii) multiplying that daily balance by the applicable daily periodic rate, (iii) adding together the resulting 

amounts for each day in the billing cycle. The total periodic INTEREST CHARGES for the billing cycle 

is the sum of the periodic INTEREST CHARGES for each purchase type rounded to the next highest 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
REVOLVING CREDIT

Each applicant may apply for individual or joint credit regardless of marital status. This application is for:

□ Individual Credit – complete applicant information.

□ Joint Credit with Spouse as Joint Applicant – complete applicant and co-applicant information.

□ Joint Credit with Non-Spouse as Joint Applicant – complete applicant and co- applicant information.

We intend to apply for joint credit:

_______________________________________     ______________________________________

Applicant Sign Here 

               Co-Applicant Sign Here

DEALER USE ONLY

Applicant’s identification was verified via viewing an unexpired driver’s license unless one of the following 

is checked: Unexpired:   ___ State Issued ID Card     ___ Passport     ___Social Security Card

Co-Applicant’s  identification  was  verified  via  viewing  an  unexpired  driver’s  license  unless  one  of  the 

following is checked: Unexpired:   ___ State Issued ID Card    ___ Passport     ___Social Security Card

Verified By:  _________________________________________________________________________

Dealer # _________________Initial Sale $__________________Down Payment $_____

In this Agreement “you” and “your” refer to all persons applying for credit and “we”, “us”, 

and “our” refer to Dealer and its assigns. 

CUSTOMER CREDIT APPLICATION

APPLICANT INFORMATION   (Please Type or Print Clearly)

Check if you are NOT a US Citizen           □     No. of Dependents

Social Security Number             Date of Birth           E-mail Address           

First Name                                     Middle                         Last Name

Residence Address (No PO Box allowed)                                     Time at Residence

                                                                                                           Yrs.             Mos.

City                                                              State                                      Zip

□ Own                              Monthly Mortgage Payment                   Home Value                                      

□ Rent                               $                                                         $                                                        

Home Phone Number                Cell Phone Number                    Work Phone Number

             /                /                            /                /                                 /                /

Previous Employer          Occupation                      Gross Monthly Salary   Length of Employment

                                                                             $                                           Yrs.         Mos.               

Alimony, child support or separate maintenance income need not be revealed if you do not wish to 

have it considered as a basis for repaying this obligation.

Other Income                    Source                                               Monthly Amount

$                                                                                               $

PERSONAL REFERENCE   (Not Living With You)

Name

Relationship                                                                 Phone Number

                                                                                                   /                /

CO-APPLICANT INFORMATION   (For Joint Applications Only)

Check if you are NOT a US Citizen           □     No. of Dependents 

Social Security Number             Date of Birth           E-mail Address

First Name                                     Middle                         Last Name

Residence Address (No PO Box allowed)                                     Time at Residence 

                                                                                                            Yrs.             Mos.

City                                                              State                                      Zip

Home Phone Number                Cell Phone Number                    Work Phone Number

             /                /                            /             /                                     /             /

Present Employer           Occupation                      Gross Monthly Salary   Length of Employment

                                                                             $                                           Yrs.        Mos.

Alimony, child support or separate maintenance income need not be revealed if you do not wish to 

have it considered as a basis for repaying this obligation.

Other Income                    Source                                               Monthly Amount

$                                                                                               $

By signing this application: 1) you warrant all information you provide is true and complete; 2) you authorize 

Dealer to assign this application to Culligan Finance Company (a division of Aqua Finance, Inc.) or its assigns; 

3)  you  authorize  a  full  investigation  and  release  of  any  records  from  any  source,  including  credit  bureau 

reports, to check the accuracy of information on this application; and 4) you consent to receiving autodialed 

message calls from us or our agents on your wireless phone. You have a continuing duty to keep us informed 

if any information on this application changes. By completing and signing this application you understand that 

you have requested that we open a revolving credit account which allows you to make credit purchases on 

account as evidenced by a revolving credit sales slip, and you agree to all the terms and conditions of this 

Revolving Credit Agreement. By your signature you acknowledge that you have received and read all the 

terms of this Agreement before making any purchases on the account.

CFC-AFI-500-RCA   1-1-2016   232726

CREDIT AGREEMENT.

                                                                                                                        /           /

Applicant Signature                                                                             Date

                                                                                                                        /           /

Applicant Drivers Lic. No.                              State                                 Expiration Date

                                                                                                                        /           /

Joint Applicant Signature                                                                    Date

                                                                                                                        /           /

Joint Applicant Drivers Lic. No.                     State                                   Expiration Date

NOTICE TO WISCONSIN APPLICANTS: No provision of a marital property agreement, a unilateral statement under 

creditor is furnished a copy of the decree, agreement, statement, or has actual knowledge of the adverse provision prior 

to the time credit is granted. You must supply us with your spouse’s name and address in the Spouse/Joint Applicant 

section above so we can give notice of this credit transaction by mailing a copy of this application.  If you are married, 

you agree that this obligation is incurred in the interest of marriage or family. 

Applicant Signature:_________________________________________________________________

CREDIT REPORT NOTICE: We may request a credit report for any legitimate purpose associated with 

your application for credit, extending credit, modifying the terms of your credit agreement, or collection 

on your account. On your request we will inform you if such a report was ordered and will give you the 

name and address of the credit reporting agency that furnished the report.

NOTICE: The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit 

applicants on the basis of race, color, religion, national origin, sex, 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 

the law concerning this creditor is the Federal Trade Commission.

Delaware residents: Service charges not in excess of those permitted by law will be charged on 

the outstanding balances from month to month.

Maryland residents: Finance charges will be made in amounts or at rates not in excess of those 

permitted by law.

ASSIGNMENT:  Should Culligan Finance Company (a division of Aqua Finance, Inc.) (“CFC”) acquire 

your  account  as  a  result  of  your  credit  application,  CFC  may  further  assign  your  credit  transaction.  

If  your  transaction  is  assigned  to  Connexus  Credit  Union  (“Connexus”)  you  will  be  required  to 

become a member.  Membership will be granted through joining the nonprofit Connexus Association 

(“Association”), a 501(c)(3) entity established to conduct charitable giving throughout the United States.  

In that event, and by signing this application, you agree to join Connexus and the Association, and the 

terms of membership in each organization.

AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS

By  signing  below,  I  hereby  authorize  the  initiation  of  a  periodic  deduction  from  my  account  at  the  financial 

institution  named  below  through  the  ACH  system  and  authorize  said  institution  to  debit  my  account  for  the 

amount and at the frequency set forth below.  I acknowledge that this request does not violate the provisions of 

United States law as it applies to ACH transactions.  I understand I have a right to stop this au tomatic payment 

by notifying either the institution named below or CFC, in writing, at least three (3) business days prior to the day 

my account is scheduled to be charged and that there may be a fee for that service.  Further I agree that CFC 

will require written confirmation of an oral stop-payment order within fourteen (14) days.  This will be a permanent 

stop payment on this preauthorized payment.  I may, however, establish a new preauthorized payment from the 

same financial institution or company in the future.  I also authorize adjustment entries in the event of erroneous 

transactions on my account.  I agree to hold CFC harmless for any expenses, including fees, incurred as a result 

of its inability to process a scheduled preauthorized withdrawal due to:  my having supplied incorrect information, 

its having acted on a stop payment order, or there being insufficient funds in the account I have indicated.

Monthly Payment_________________________

Day of Month for Withdrawal ____________ Month First Payment is to be Drawn ______________

Bank Name ______________________________________________________________________

Bank  Address_____________________________________________________________________

If not filled in, you are authorized to deduct the payment amount set forth in my Revolving Credit Sales Slip for the account listed on my voided check.

IMPORTANT: PLEASE ATTACH A VOIDED CHECK WITH CORRECT ENCODING INFORMATION

Type of Account: □ Checking □ Savings

Bank Routing Number _____________________ Depositor Account Number ______________

X______________________________________  X _____________________________________

Signature of Depositor                                            (if joint account, both must sign)

□ I would like to receive my monthly account statements by email and have access to pay my bill online.

IF THIS IS A JOINT ACCOUNT YOU UNDERSTAND THAT EACH APPLICANT HAS THE RIGHT TO USE THE 

ACCOUNT TO THE CREDIT LIMIT AND THAT CO-APPLICANTS ARE JOINTLY AND SEVERALLY LIABLE 

FOR ALL PURCHASES ON THE ACCOUNT.  See State Notices for important information regarding this 

credit application and agreement. No agreement exists between us until this application is approved.

SOCIAL  SECURITY  NUMBER/TAXPAYER  IDENTIFICATION  NUMBER:    Under  penalties  of  perjury,  I  certify  that:  1)

The number shown on Page 1 of this Credit Application is my correct taxpayer identification number (or I am waiting for a 

number to  be issued to me),  2) I am not subject to backup withholding because: (a) I am exempt from backup withholding; 

or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of 

a failure to report all interest or dividends; or (c) the IRS has notified me that I am no longer subject to backup withholding; 

and 3) I am a U.S. person (including a U.S. resident alien). Certification Instructions: Cross out item 2 above if you have 

been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest 

and dividends on your tax return.  Cross out item 3 and complete a W-8 BEN if you qualify and are not a U. S. Person.

The Internal Revenue Service does not require your consent to any provision of this document other 

than the certification required to avoid backup withholding.

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Your  Minimum  Monthly  Payment  will  be  between  2%  and  5%  of  the  “Highest  Monthly  Charge” 

balance since your Monthly Charge Balance was zero (less any Special Payment Plans) as will be 

shown on your billing statement, rounded to the next highest dollar, or $15, whichever is greater.  If 

you are a participant in specified Promotion Plans, your Minimum Monthly Payment will be between 

1%  (for  first  12  months)  and  2%  (thereafter)  of  the  “Highest  Monthly  Charge”  balance  or  $15, 

whichever is greater.  A finance charge will be computed on your outstanding balance each month.

DO  NOT  SIGN  BELOW  UNLESS  MERCHANT  HAS  PROVIDED  THE  ATTACHED  DISCLOSURES  AND 

TERMS. BY YOUR SIGNATURE BELOW YOU ACKNOWLEDGE RECEIPT OF THE ATTACHED REVOLVING 

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IMPORTANT INFORMATION ABOUT YOUR ACCOUNT
KEEP THIS INFORMATION FOR YOUR RECORD

REVOLVING CREDIT AGREEMENT AND DISCLOSURE STATEMENT
Dealer may assign all rights under this Agreement and any credit sale made pursuant to it (as evidenced by a revolving 
credit sales slip) to Culligan Finance Company (a division of Aqua Finance, Inc.) (“CFC”) and to CFC’s further assigns. 
***Not  all  offers  will  contain  introductory  rates.  If  not  otherwise 
specified on Revolving Credit Sales Slip or Promo Addendum, then 
your APR is the maximum non-introductory state APR in table, below.

Interest Rates and Interest Charges

Annual Percentage
Rate (APR)
for Purchases 

Penalty APR 
and When it Applies**

Paying Interest 

Minimum Interest Charge

For Credit Card Tips from 
the Consumer Financial 
Protection Bureau

Fees 
Penalty Fees
•Late Payment 
•Returned Payment 

Introductory rates between 0% and 
9.9%, ranging from 6 months to 12 
months.***  Non-introductory rates 
between 5.9% and 17.99%.
All rates are based on the specific 
promotion or your credit worthiness, and 
dealer participation. (Maximum APR 
Varies By State. See table below *)
21% (see table below for applicability 
in your state**) This APR may be 
applied to your account if you make a 
late payment.  
How Long Will the Penalty Rate 
Apply?:  The Penalty APR may 
remain in effect indefinitely.
Interest Charges begin on the date a 
purchase is posted to your account, 
except in states requiring a grace 
period, in which case your due date 
is at least 25 days after the close 
of each billing cycle and we will not 
charge you interest if you pay your 
entire balance by the due date.

If you are charged interest, the charge 
will be no less than $0.50.

To learn more about factors to consider 
when applying for or using a credit 
card, visit the Consumer Financial 
Protection Bureau’s website at 
http://www.consumerfinance.gov/learnmore.

Fees Vary By State
Up to $35 See Paragraph 11 of Agreement
Up to $35 See Paragraph 12 of Agreement

How We Will Calculate Your Balance: We use a method called the “Daily 
Balance (including new purchases).”  See your account Agreement for more 
details.
Loss of Introductory APR: We may end your introductory APR and apply the 
Penalty APR if you make a late payment.
Billing Rights: Information on your rights to dispute transactions and how to 
exercise those rights is provided in your account agreement.
This  information  is  accurate  on  the  date  of  your  application  and  initial 
purchase.  If any of this information changes you will be notified at least 
45 days prior to any change and how to contact us regarding any change.  
All terms are subject to change.

CFC-AFI-500-RCA   1-1-2016   232726

MN -$7.80 maximum

KY & WY ($10 minimum); 

AL, ID & MI ($15 minimum);

HI, NE, VA

UT

OK ($5 minimum)

SC, TX, D.C.

AZ, CT, IL, LA, MD, ME, PA

NM

MA

5% of payment due

5% of payment due;  $35 maximum*

5% of payment due; $30 maximum*

     5% of payment due;            $20 maximum

5% of payment due; $15 maximum

5% of payment due; $10 maximum

5% of payment due; $5 maximum

10% of payment due; $10 maximum

*Maximum Non-Introductory State APR Rates
Arkansas

17%
17.99% All other states
** The penalty APR rate does not apply in the following states: Arkansas, Colorado, 
Connecticut,  Delaware,  Florida,  Illinois,  Kansas,  Louisiana,  Maine,  Maryland, 
Massachusetts,  Michigan,  Minnesota,  Missouri,  Nebraska,  North  Carolina, 
Oklahoma, Pennsylvania, Rhode Island, South Carolina, Texas, and Wyoming.

1. GENERAL:  If your credit application is approved and we open a revolving credit account for you, 
you may purchase household goods and services on credit from the dealer where you opened your 
account.  Purchases  are  pursuant  to  a  revolving  credit  sales  slip  and  you  agree  that  all  sales  are 
subject to the terms of this Agreement. 

2.  PROMISE  TO  PAY:    You  agree  to  pay  for  all  purchases  made  on  your  account,  INTEREST 
CHARGES, and other applicable charges or fees under this Agreement incurred by you or anyone 
you  authorize  or  permit  to  use  your  account.  If  this  account  is  a  joint  account,  each  joint  account 
holder agrees to pay, and all account holders are jointly and severally responsible for all amounts 
owed on the account. If your account is referred for collections to an attorney who is not our salaried 
employee, you agree to pay reasonable attorney fees and reasonable collection costs to the extent 
allowed by law in your state. If your state does not allow attorney fees (IA, ME, OH, and WI), you 
agree to pay any statutory attorney fees and costs that may be awarded to us by a court of law. 

cent. Any Daily Balance less than zero will be treated as zero. A minimum INTEREST CHARGE 
of no less than $0.50 is added to your account in any billing cycle your account is subject to an 
INTEREST CHARGE, except in states where prohibited by law. The grace period is 25 days in 
Louisiana, Maine, Maryland, Massachusetts, Mississippi, North Carolina, and Virginia and 30 days 
in Nebraska & Vermont on new purchases where your account balance is $0 or you have paid your 
previous balance due in full by the end of the billing cycle.  

9.  DEFAULT:    You  are  in  default  if:  (a)  you  fail  to  make  a  required  payment  when  due  on  two 
occasions in any 12 month period; (b) you fail to observe or perform any of the other covenants or 
duties contained in this Agreement if the failure materially impairs the condition, value or protection 
of our right in any Collateral, or materially impairs your ability to pay any amounts on your billing 
statement when due. You will receive a Notice of Right to Cure in the following states: Colorado, 
Iowa, Kansas, Maine, Massachusetts, Missouri, Nebraska, Pennsylvania, and Wisconsin. If you fail 
to cure within the time allowed in your notice or within 30 days if you live in a state with no notice 
requirement, we may accelerate your balance.

10. SPECIAL CREDIT PROMOTION PLANS: We may occasionally offer special credit promotion 
plans for you to participate in at your option.

11. LATE FEE:  If your payment is more than 10 days late (15 days in ME, MA, ID or SD and 30 
days in NC), you may be charged a late fee up to the amount indicated below for your state of 
residence.  The late fee will be added to your account balance.

KS & MO if payment due is less than $25

AK, AR, CA, FL, KS, MO, MT, NJ, NC, OH, RI, SD, TN  

CO, IN, IA, MS, NV, NH, NY, ND, OR, VT, WA, WI

3. CREDIT LIMIT:  We set a credit limit on your account which we may modify at any time for any 
reason not prohibited by law. You may not charge purchases if it causes you to exceed your credit 
limit unless we allow such purchases. You agree to pay all amounts over your credit limit.

GA

4. BILLING STATEMENT:  We will mail you a statement each month you have an account balance 
greater than $1.00 at the address we have in our records. This statement will show credit purchases, 
late  charges,  NSF  fees,  previous  balance,  new  balance,  payments  received,  credits,  INTEREST 
CHARGES, total minimum payment due, and payment due date.

5.  MINIMUM  MONTHLY  PAYMENT:    All  payments,  except  disputed  payments,  must  be  mailed 
or delivered to the Payment Processing Center address shown on your monthly billing statement. 
All payments must be made by electronic fund transfer, check or money order. Do not send cash. 
Cash or other nonconforming methods of payment may be rejected. We may accept partial or late 
payments or checks marked “payment in full” or other restrictive endorsement without losing our right 
to receive the full amount owed. Your billing statement will include requirements for you to follow in 
making payments. Disputed payments, including those which indicate that the payment constitutes 
“payment in full” of the amount owed, must be mailed or delivered to the Customer Service address 
listed below. You agree to pay us at least the Total Minimum Monthly  Payment  reflected  on  your 
statement. You may pay more than the Total Minimum Monthly Payment and you may pay the entire 
amount due at any time.  The Total Minimum Monthly Payment Due shown on your billing statement 
will be the sum of the Minimum Monthly Payment plus all past due amounts, late fees, and other 
charges. The Minimum Monthly Payment is calculated at the end of the first month in which you make 
a  purchase,  and  will  be  calculated  each  month  in  which  you  make  an  additional  purchase.    Your 
Minimum Monthly Payments will be between 2% and 5% of the “Highest Monthly Charge” balance 
since your Monthly Charge Balance was zero (or if you participate in specified Promotion Plans, Your 
Minimum Monthly Payments will be between 1% and 2% of the “Highest Monthly Charge” balance 
since your Monthly Charge Balance was zero), less any Special Payment Plans as shown on your 
billing statement rounded to the next higher dollar, or $15, whichever is greater, unless your account 
balance is less than $15 in which case the Minimum Monthly Payment will be equal to the account 
balance. You agree that any payment may be returned if your check is (i) not drawn in U.S. dollars 
on funds on deposit in the U.S.; (ii) missing a signature; (iii) drawn with different numeric and written 
amounts; (iv) contains a restrictive endorsement; (v) postdated; or (vi) not paid on presentment.  If 
you do not make a Total Minimum Monthly Payment within 60 days of its due date, we may apply the 
Penalty APR to your account, if allowed by the state of your residence.  We will give you advanced 
notice of the date the Penalty APR is effective.  The Penalty APR may remain in effect indefinitely, 
unless you make the first six consecutive Total Minimum Monthly Payments when due following the 
effective date of the application of the Penalty APR to your account.

6. ELECTRONIC FUND TRANSFER:  When you provide a check, you authorize us either to use 
information  from  your  check  to  make  a  one-time  electronic  fund  transfer  from  your  account  or  to 
process the transaction as a check.  When we use your check to make an electronic fund transfer, 
funds may be withdrawn from your account as soon as the same day we receive your payment, and 
you may not receive your check back from your financial institution. If there are insufficient funds in 
your account you authorize us to charge an NSF Fee as indicated below and collect that amount 
through an electronic fund transfer from your account.

7. PREPAYMENT:  You may pay your entire account balance at any time without penalty.  If you do 
not pay the entire balance in full, you must make a minimum payment each month by the payment 
due date that appears on your billing statement. Under federal law, we are not required to refund any 
amounts less than $1.00.

8. INTEREST CHARGE:  INTEREST CHARGES begin the date a purchase is posted to your account 
and accrue as long as your account has a balance, except in states with a mandatory grace period. 
The INTEREST CHARGE is computed by applying a daily periodic rate of between 0% and .02712% 
(corresponding to an APR of 9.9%) for an Introductory APR, or between .01616% (corresponding to 
an APR of 5.9%) and .04929% (corresponding to an APR of 17.99%) for a Non-Introductory APR, to 
the daily balance. The daily balance is calculated by taking the beginning balance in the account each 
day, adding any new purchases, and subtracting any unpaid interest or other finance charges and 
any payments and credits. The INTEREST CHARGE is calculated by (i) taking each daily balance, 
(ii) multiplying that daily balance by the applicable daily periodic rate, (iii) adding together the resulting 
amounts for each day in the billing cycle. The total periodic INTEREST CHARGES for the billing cycle 
is the sum of the periodic INTEREST CHARGES for each purchase type rounded to the next highest 

*($25 maximum-first occurrence in more than 6 months.)

12. RETURNED PAYMENT / NSF FEE:  If any payment instrument or method is dishonored by 
your bank or the drawee, you agree to pay an NSF fee up to the amount indicated below for your 
state of residence.  No NSF fee will be charged if your state of residence is DE, MD, NE or WY.  If 
required by your state, you will receive a notice with instructions about the NSF service or collection 
fees, and if you fail to pay the fee we will add it to your account balance.  We are not required to 
present payment instruments more than once to the drawee for payment. This fee will be added 
to your account balance. 

MA, ME, AZ (greater of $10 or bank fee)

CA, MS, MO

CT, D.C., ID, IA, NJ, NY, OH, PA, UT, VT

AR, CO, FL, IL, IN, KY, LA, MI, MN, NV, NH, NM, NC, OK,  RI, TX, WI 

AL, AK, GA, HI, KS, MT, SC, SD, TN

ND, OR, VA, WA

*($25 maximum-first occurrence in more than 6 months.)  

13.  ACCOUNT  INFORMATION:    You  authorize  us  to  furnish  information  about  your  account  to 
credit reporting agencies and anyone else who may lawfully receive such information. On request, 
you agree to promptly provide us with accurate and updated financial and employment information. 
You agree to give us prompt notice of any change in your name, address, and telephone numbers. 
Where allowed by law, you authorize the Department of Motor Vehicles to release your address if 
it becomes necessary to locate you.

14. CHANGE IN TERMS:  We may change the terms of this Agreement, as permitted by law, at 
any time. You will be notified of changes in accordance with applicable state and federal law, but in 
the event your state does not specify a time period, you will be notified at least 45 days in advance 
of any such changes, and such notice will be sent to your current address as shown on our records 
for your account. We count the days from the date we mail the notification. 

15.  CREDIT  INVESTIGATION:    You  agree  we  may  investigate  your  credit,  employment,  and 
financial status. You authorize us to obtain a credit report and any other information about your 
creditworthiness  in  connection  with  processing  your  application  for  credit,  and  subsequently  in 
connection with any extension of credit, request to increase credit limits, or any renewal or update 
of your account, or to take collection action on the account, or to investigate disputes regarding 
the account. At your request, we will inform you if such reports were ordered, and the names of 
the credit bureaus that provided reports. You authorize the Department of Defense and its various 
departments and commands to verify your social security number or other identifier and disclose 
your  home  address  to  the  authorized  holder  of  this  Agreement  for  purposes  of  performing  or 
enforcing  the  terms  of  this  Agreement.  You  authorize  any  past  or  present  employer  to  confirm 
employment  or  communicate  with  us  regarding  your  indebtedness  to  us  if  you  fail  to  meet  the 
terms  and  conditions  of  this  Agreement.  We  use  information  furnished  solely  in  connection  with 
performing or enforcing the terms of this Agreement. 

$5

$10

$15

$25

$10

$15

$20

$25

$30*

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REVOLVING CREDIT

Each applicant may apply for individual or joint credit regardless of marital status. This application is for:

□ Individual Credit – complete applicant information.

□ Joint Credit with Spouse as Joint Applicant – complete applicant and co-applicant information.

□ Joint Credit with Non-Spouse as Joint Applicant – complete applicant and co- applicant information.

We intend to apply for joint credit:

_______________________________________     ______________________________________

Applicant Sign Here 

               Co-Applicant Sign Here

DEALER USE ONLY

Applicant’s identification was verified via viewing an unexpired driver’s license unless one of the following 

is checked: Unexpired:   ___ State Issued ID Card     ___ Passport     ___Social Security Card

Co-Applicant’s  identification  was  verified  via  viewing  an  unexpired  driver’s  license  unless  one  of  the 

following is checked: Unexpired:   ___ State Issued ID Card    ___ Passport     ___Social Security Card

Verified By:  _________________________________________________________________________

Dealer # _________________Initial Sale $__________________Down Payment $_____

In this Agreement “you” and “your” refer to all persons applying for credit and “we”, “us”, 

and “our” refer to Dealer and its assigns. 

CUSTOMER CREDIT APPLICATION

APPLICANT INFORMATION   (Please Type or Print Clearly)

Check if you are NOT a US Citizen           □     No. of Dependents

Social Security Number             Date of Birth           E-mail Address           

First Name                                     Middle                         Last Name

Residence Address (No PO Box allowed)                                     Time at Residence

                                                                                                           Yrs.             Mos.

City                                                              State                                      Zip

□ Own                              Monthly Mortgage Payment                   Home Value                                      

□ Rent                               $                                                         $                                                        

Home Phone Number                Cell Phone Number                    Work Phone Number

             /                /                            /                /                                 /                /

Previous Employer          Occupation                      Gross Monthly Salary   Length of Employment

                                                                             $                                           Yrs.         Mos.               

Alimony, child support or separate maintenance income need not be revealed if you do not wish to 

have it considered as a basis for repaying this obligation.

Other Income                    Source                                               Monthly Amount

$                                                                                               $

PERSONAL REFERENCE   (Not Living With You)

Name

Relationship                                                                 Phone Number

                                                                                                   /                /

CO-APPLICANT INFORMATION   (For Joint Applications Only)

Check if you are NOT a US Citizen           □     No. of Dependents 

Social Security Number             Date of Birth           E-mail Address

First Name                                     Middle                         Last Name

Residence Address (No PO Box allowed)                                     Time at Residence 

                                                                                                            Yrs.             Mos.

City                                                              State                                      Zip

Home Phone Number                Cell Phone Number                    Work Phone Number

             /                /                            /             /                                     /             /

Present Employer           Occupation                      Gross Monthly Salary   Length of Employment

                                                                             $                                           Yrs.        Mos.

Alimony, child support or separate maintenance income need not be revealed if you do not wish to 

have it considered as a basis for repaying this obligation.

Other Income                    Source                                               Monthly Amount

IF THIS IS A JOINT ACCOUNT YOU UNDERSTAND THAT EACH APPLICANT HAS THE RIGHT TO USE THE 

ACCOUNT TO THE CREDIT LIMIT AND THAT CO-APPLICANTS ARE JOINTLY AND SEVERALLY LIABLE 

FOR ALL PURCHASES ON THE ACCOUNT.  See State Notices for important information regarding this 

credit application and agreement. No agreement exists between us until this application is approved.

SOCIAL  SECURITY  NUMBER/TAXPAYER  IDENTIFICATION  NUMBER:    Under  penalties  of  perjury,  I  certify  that:  1)

The number shown on Page 1 of this Credit Application is my correct taxpayer identification number (or I am waiting for a 

number to  be issued to me),  2) I am not subject to backup withholding because: (a) I am exempt from backup withholding; 

or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of 

a failure to report all interest or dividends; or (c) the IRS has notified me that I am no longer subject to backup withholding; 

and 3) I am a U.S. person (including a U.S. resident alien). Certification Instructions: Cross out item 2 above if you have 

been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest 

and dividends on your tax return.  Cross out item 3 and complete a W-8 BEN if you qualify and are not a U. S. Person.

The Internal Revenue Service does not require your consent to any provision of this document other 

than the certification required to avoid backup withholding.

Your  Minimum  Monthly  Payment  will  be  between  2%  and  5%  of  the  “Highest  Monthly  Charge” 

balance since your Monthly Charge Balance was zero (less any Special Payment Plans) as will be 

shown on your billing statement, rounded to the next highest dollar, or $15, whichever is greater.  If 

you are a participant in specified Promotion Plans, your Minimum Monthly Payment will be between 

1%  (for  first  12  months)  and  2%  (thereafter)  of  the  “Highest  Monthly  Charge”  balance  or  $15, 

whichever is greater.  A finance charge will be computed on your outstanding balance each month.

DO  NOT  SIGN  BELOW  UNLESS  MERCHANT  HAS  PROVIDED  THE  ATTACHED  DISCLOSURES  AND 

TERMS. BY YOUR SIGNATURE BELOW YOU ACKNOWLEDGE RECEIPT OF THE ATTACHED REVOLVING 

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CREDIT AGREEMENT.

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Applicant Signature                                                                             Date

                                                                                                                        /           /

Applicant Drivers Lic. No.                              State                                 Expiration Date

                                                                                                                        /           /

Joint Applicant Signature                                                                    Date

                                                                                                                        /           /

Joint Applicant Drivers Lic. No.                     State                                   Expiration Date

NOTICE TO WISCONSIN APPLICANTS: No provision of a marital property agreement, a unilateral statement under 

Wis. Stats. §766.59, or a court decree under Wis. Stats. §766.70 adversely affect the interest of the creditor unless the 

creditor is furnished a copy of the decree, agreement, statement, or has actual knowledge of the adverse provision prior 

to the time credit is granted. You must supply us with your spouse’s name and address in the Spouse/Joint Applicant 

section above so we can give notice of this credit transaction by mailing a copy of this application.  If you are married, 

you agree that this obligation is incurred in the interest of marriage or family. 

Applicant Signature:_________________________________________________________________

CREDIT REPORT NOTICE: We may request a credit report for any legitimate purpose associated with 

your application for credit, extending credit, modifying the terms of your credit agreement, or collection 

on your account. On your request we will inform you if such a report was ordered and will give you the 

name and address of the credit reporting agency that furnished the report.

NOTICE: The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit 

applicants on the basis of race, color, religion, national origin, sex, 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 

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the law concerning this creditor is the Federal Trade Commission.

Delaware residents: Service charges not in excess of those permitted by law will be charged on 

the outstanding balances from month to month.

Maryland residents: Finance charges will be made in amounts or at rates not in excess of those 

permitted by law.

ASSIGNMENT:  Should Culligan Finance Company (a division of Aqua Finance, Inc.) (“CFC”) acquire 

your  account  as  a  result  of  your  credit  application,  CFC  may  further  assign  your  credit  transaction.  

If  your  transaction  is  assigned  to  Connexus  Credit  Union  (“Connexus”)  you  will  be  required  to 

become a member.  Membership will be granted through joining the nonprofit Connexus Association 

(“Association”), a 501(c)(3) entity established to conduct charitable giving throughout the United States.  

In that event, and by signing this application, you agree to join Connexus and the Association, and the 

terms of membership in each organization.

AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS

By  signing  below,  I  hereby  authorize  the  initiation  of  a  periodic  deduction  from  my  account  at  the  financial 

institution  named  below  through  the  ACH  system  and  authorize  said  institution  to  debit  my  account  for  the 

amount and at the frequency set forth below.  I acknowledge that this request does not violate the provisions of 

United States law as it applies to ACH transactions.  I understand I have a right to stop this au tomatic payment 

by notifying either the institution named below or CFC, in writing, at least three (3) business days prior to the day 

my account is scheduled to be charged and that there may be a fee for that service.  Further I agree that CFC 

will require written confirmation of an oral stop-payment order within fourteen (14) days.  This will be a permanent 

stop payment on this preauthorized payment.  I may, however, establish a new preauthorized payment from the 

same financial institution or company in the future.  I also authorize adjustment entries in the event of erroneous 

transactions on my account.  I agree to hold CFC harmless for any expenses, including fees, incurred as a result 

of its inability to process a scheduled preauthorized withdrawal due to:  my having supplied incorrect information, 

its having acted on a stop payment order, or there being insufficient funds in the account I have indicated.

Monthly Payment_________________________

$                                                                                               $

By signing this application: 1) you warrant all information you provide is true and complete; 2) you authorize 

Dealer to assign this application to Culligan Finance Company (a division of Aqua Finance, Inc.) or its assigns; 

3)  you  authorize  a  full  investigation  and  release  of  any  records  from  any  source,  including  credit  bureau 

reports, to check the accuracy of information on this application; and 4) you consent to receiving autodialed 

message calls from us or our agents on your wireless phone. You have a continuing duty to keep us informed 

if any information on this application changes. By completing and signing this application you understand that 

you have requested that we open a revolving credit account which allows you to make credit purchases on 

account as evidenced by a revolving credit sales slip, and you agree to all the terms and conditions of this 

Revolving Credit Agreement. By your signature you acknowledge that you have received and read all the 

terms of this Agreement before making any purchases on the account.

CFC-AFI-500-RCA   1-1-2016   232726

Bank  Address_____________________________________________________________________

If not filled in, you are authorized to deduct the payment amount set forth in my Revolving Credit Sales Slip for the account listed on my voided check.

IMPORTANT: PLEASE ATTACH A VOIDED CHECK WITH CORRECT ENCODING INFORMATION

Type of Account: □ Checking □ Savings

Bank Routing Number _____________________ Depositor Account Number ______________

X______________________________________  X _____________________________________

Signature of Depositor                                            (if joint account, both must sign)

□ I would like to receive my monthly account statements by email and have access to pay my bill online.

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REVOLVING CREDIT AGREEMENT AND DISCLOSURE STATEMENT

Dealer may assign all rights under this Agreement and any credit sale made pursuant to it (as evidenced by a revolving 

credit sales slip) to Culligan Finance Company (a division of Aqua Finance, Inc.) (“CFC”) and to CFC’s further assigns. 

***Not  all  offers  will  contain  introductory  rates.  If  not  otherwise 

specified on Revolving Credit Sales Slip or Promo Addendum, then 

your APR is the maximum non-introductory state APR in table, below.

Interest Rates and Interest Charges

Annual Percentage

Rate (APR)

for Purchases 

Penalty APR 

and When it Applies**

Paying Interest 

Minimum Interest Charge

For Credit Card Tips from 

the Consumer Financial 

Protection Bureau

Fees 

Penalty Fees

•Late Payment 

•Returned Payment 

Introductory rates between 0% and 

9.9%, ranging from 6 months to 12 

months.***  Non-introductory rates 

between 5.9% and 17.99%.

All rates are based on the specific 

promotion or your credit worthiness, and 

dealer participation. (Maximum APR 

Varies By State. See table below *)

21% (see table below for applicability 

in your state**) This APR may be 

applied to your account if you make a 

late payment.  

How Long Will the Penalty Rate 

Apply?:  The Penalty APR may 

remain in effect indefinitely.

Interest Charges begin on the date a 

purchase is posted to your account, 

except in states requiring a grace 

period, in which case your due date 

is at least 25 days after the close 

of each billing cycle and we will not 

charge you interest if you pay your 

entire balance by the due date.

If you are charged interest, the charge 

will be no less than $0.50.

To learn more about factors to consider 

when applying for or using a credit 

card, visit the Consumer Financial 

Protection Bureau’s website at 

http://www.consumerfinance.gov/learnmore.

Fees Vary By State

Up to $35 See Paragraph 11 of Agreement

Up to $35 See Paragraph 12 of Agreement

How We Will Calculate Your Balance: We use a method called the “Daily 

Balance (including new purchases).”  See your account Agreement for more 

details.

This  information  is  accurate  on  the  date  of  your  application  and  initial 

purchase.  If any of this information changes you will be notified at least 

45 days prior to any change and how to contact us regarding any change.  

All terms are subject to change.

IMPORTANT INFORMATION ABOUT YOUR ACCOUNT

KEEP THIS INFORMATION FOR YOUR RECORD

*Maximum Non-Introductory State APR Rates

17%

Arkansas

17.99% All other states

** The penalty APR rate does not apply in the following states: Arkansas, Colorado, 
Connecticut,  Delaware,  Florida,  Illinois,  Kansas,  Louisiana,  Maine,  Maryland, 
Massachusetts,  Michigan,  Minnesota,  Missouri,  Nebraska,  North  Carolina, 

Oklahoma, Pennsylvania, Rhode Island, South Carolina, Texas, and Wyoming.

1. GENERAL:  If your credit application is approved and we open a revolving credit account for you, 
you may purchase household goods and services on credit from the dealer where you opened your 
account.  Purchases  are  pursuant  to  a  revolving  credit  sales  slip  and  you  agree  that  all  sales  are 

subject to the terms of this Agreement. 

2.  PROMISE  TO  PAY:    You  agree  to  pay  for  all  purchases  made  on  your  account,  INTEREST 
CHARGES, and other applicable charges or fees under this Agreement incurred by you or anyone 
you  authorize  or  permit  to  use  your  account.  If  this  account  is  a  joint  account,  each  joint  account 
holder agrees to pay, and all account holders are jointly and severally responsible for all amounts 
owed on the account. If your account is referred for collections to an attorney who is not our salaried 
employee, you agree to pay reasonable attorney fees and reasonable collection costs to the extent 
allowed by law in your state. If your state does not allow attorney fees (IA, ME, OH, and WI), you 

agree to pay any statutory attorney fees and costs that may be awarded to us by a court of law. 

3. CREDIT LIMIT:  We set a credit limit on your account which we may modify at any time for any 
reason not prohibited by law. You may not charge purchases if it causes you to exceed your credit 

limit unless we allow such purchases. You agree to pay all amounts over your credit limit.

4. BILLING STATEMENT:  We will mail you a statement each month you have an account balance 
greater than $1.00 at the address we have in our records. This statement will show credit purchases, 
late  charges,  NSF  fees,  previous  balance,  new  balance,  payments  received,  credits,  INTEREST 

CHARGES, total minimum payment due, and payment due date.

5.  MINIMUM  MONTHLY  PAYMENT:    All  payments,  except  disputed  payments,  must  be  mailed 
or delivered to the Payment Processing Center address shown on your monthly billing statement. 
All payments must be made by electronic fund transfer, check or money order. Do not send cash. 
Cash or other nonconforming methods of payment may be rejected. We may accept partial or late 
payments or checks marked “payment in full” or other restrictive endorsement without losing our right 
to receive the full amount owed. Your billing statement will include requirements for you to follow in 
making payments. Disputed payments, including those which indicate that the payment constitutes 
“payment in full” of the amount owed, must be mailed or delivered to the Customer Service address 
listed below. You agree to pay us at least the Total Minimum  Monthly  Payment  reflected  on  your 
statement. You may pay more than the Total Minimum Monthly Payment and you may pay the entire 
amount due at any time.  The Total Minimum Monthly Payment Due shown on your billing statement 
will be the sum of the Minimum Monthly Payment plus all past due amounts, late fees, and other 
charges. The Minimum Monthly Payment is calculated at the end of the first month in which you make 
a  purchase,  and  will  be  calculated  each  month  in  which  you  make  an  additional  purchase.    Your 
Minimum Monthly Payments will be between 2% and 5% of the “Highest Monthly Charge” balance 
since your Monthly Charge Balance was zero (or if you participate in specified Promotion Plans, Your 
Minimum Monthly Payments will be between 1% and 2% of the “Highest Monthly Charge” balance 
since your Monthly Charge Balance was zero), less any Special Payment Plans as shown on your 
billing statement rounded to the next higher dollar, or $15, whichever is greater, unless your account 
balance is less than $15 in which case the Minimum Monthly Payment will be equal to the account 
balance. You agree that any payment may be returned if your check is (i) not drawn in U.S. dollars 
on funds on deposit in the U.S.; (ii) missing a signature; (iii) drawn with different numeric and written 
amounts; (iv) contains a restrictive endorsement; (v) postdated; or (vi) not paid on presentment.  If 
you do not make a Total Minimum Monthly Payment within 60 days of its due date, we may apply the 
Penalty APR to your account, if allowed by the state of your residence.  We will give you advanced 
notice of the date the Penalty APR is effective.  The Penalty APR may remain in effect indefinitely, 
unless you make the first six consecutive Total Minimum Monthly Payments when due following the 

effective date of the application of the Penalty APR to your account.

6. ELECTRONIC FUND TRANSFER:  When you provide a check, you authorize us either to use 
information  from  your  check  to  make  a  one-time  electronic  fund  transfer  from  your  account  or  to 
process the transaction as a check.  When we use your check to make an electronic fund transfer, 
funds may be withdrawn from your account as soon as the same day we receive your payment, and 
you may not receive your check back from your financial institution. If there are insufficient funds in 
your account you authorize us to charge an NSF Fee as indicated below and collect that amount 

through an electronic fund transfer from your account.

Day of Month for Withdrawal ____________ Month First Payment is to be Drawn ______________

Billing Rights: Information on your rights to dispute transactions and how to 

amounts less than $1.00.

Bank Name ______________________________________________________________________

exercise those rights is provided in your account agreement.

Loss of Introductory APR: We may end your introductory APR and apply the 

Penalty APR if you make a late payment.

7. PREPAYMENT:  You may pay your entire account balance at any time without penalty.  If you do 
not pay the entire balance in full, you must make a minimum payment each month by the payment 
due date that appears on your billing statement. Under federal law, we are not required to refund any 

8. INTEREST CHARGE:  INTEREST CHARGES begin the date a purchase is posted to your account 
and accrue as long as your account has a balance, except in states with a mandatory grace period. 
The INTEREST CHARGE is computed by applying a daily periodic rate of between 0% and .02712% 
(corresponding to an APR of 9.9%) for an Introductory APR, or between .01616% (corresponding to 
an APR of 5.9%) and .04929% (corresponding to an APR of 17.99%) for a Non-Introductory APR, to 
the daily balance. The daily balance is calculated by taking the beginning balance in the account each 
day, adding any new purchases, and subtracting any unpaid interest or other finance charges and 
any payments and credits. The INTEREST CHARGE is calculated by (i) taking each daily balance, 
(ii) multiplying that daily balance by the applicable daily periodic rate, (iii) adding together the resulting 
amounts for each day in the billing cycle. The total periodic INTEREST CHARGES for the billing cycle 
is the sum of the periodic INTEREST CHARGES for each purchase type rounded to the next highest 

cent. Any Daily Balance less than zero will be treated as zero. A minimum INTEREST CHARGE 
of no less than $0.50 is added to your account in any billing cycle your account is subject to an 
INTEREST CHARGE, except in states where prohibited by law. The grace period is 25 days in 
Louisiana, Maine, Maryland, Massachusetts, Mississippi, North Carolina, and Virginia and 30 days 
in Nebraska & Vermont on new purchases where your account balance is $0 or you have paid your 
previous balance due in full by the end of the billing cycle.  

9.  DEFAULT:    You  are  in  default  if:  (a)  you  fail  to  make  a  required  payment  when  due  on  two 
occasions in any 12 month period; (b) you fail to observe or perform any of the other covenants or 
duties contained in this Agreement if the failure materially impairs the condition, value or protection 
of our right in any Collateral, or materially impairs your ability to pay any amounts on your billing 
statement when due. You will receive a Notice of Right to Cure in the following states: Colorado, 
Iowa, Kansas, Maine, Massachusetts, Missouri, Nebraska, Pennsylvania, and Wisconsin. If you fail 
to cure within the time allowed in your notice or within 30 days if you live in a state with no notice 
requirement, we may accelerate your balance.

16. ACCOUNT CANCELLATION:  We may cancel your account at any time for any reason subject to 
the requirements of applicable law. Outstanding balances continue to accrue INTEREST CHARGES 
until paid in full, and remain subject to all terms and conditions of this Agreement. You may cancel 
your account by writing to our account service provider Culligan Finance Company (a division of Aqua 
Finance, Inc.), P.O. Box 844, Wausau, WI 54402-0844. Your notice is effective on receipt. If you cancel 
your Account, you are still responsible for all amounts owed pursuant to the terms of this Agreement. 

17. ASSIGNMENT:  This Agreement is not effective until your application has been approved by 
CFC. We have the right to assign any or all of our rights under this Agreement to any assignee of 
our choosing.  You may not assign this Agreement or any rights under it and any attempt to make 
such an assignment will be null and void. You understand that Dealer and CFC are independent 
entities and not employees or agents of one another. This Agreement legally binds the parties and 
their respective heirs, representatives, executors, administrators, successors and assigns.  

18. SEVERABILITY:  If any provision of this Agreement is deemed void or unenforceable under any 
law, rule, or regulation, all other provisions remain in effect and enforceable.

10. SPECIAL CREDIT PROMOTION PLANS: We may occasionally offer special credit promotion 
plans for you to participate in at your option.

19. NON-WAIVER:  We do not lose any of our rights under this Agreement if we delay taking action 
for any reasons.

$5
$10
$15
$25
5% of payment due

11. LATE FEE:  If your payment is more than 10 days late (15 days in ME, MA, ID or SD and 30 
days in NC), you may be charged a late fee up to the amount indicated below for your state of 
residence.  The late fee will be added to your account balance.
KS & MO if payment due is less than $25
AK, AR, CA, FL, KS, MO, MT, NJ, NC, OH, RI, SD, TN  
CO, IN, IA, MS, NV, NH, NY, ND, OR, VT, WA, WI
GA
MN -$7.80 maximum
KY & WY ($10 minimum); 
AL, ID & MI ($15 minimum);
HI, NE, VA
UT
OK ($5 minimum)
SC, TX, D.C.
AZ, CT, IL, LA, MD, ME, PA
NM
MA
*($25 maximum-first occurrence in more than 6 months.)

5% of payment due; $30 maximum*
     5% of payment due;            $20 maximum
5% of payment due; $15 maximum
5% of payment due; $10 maximum
5% of payment due; $5 maximum
10% of payment due; $10 maximum

5% of payment due;  $35 maximum*

12. RETURNED PAYMENT / NSF FEE:  If any payment instrument or method is dishonored by 
your bank or the drawee, you agree to pay an NSF fee up to the amount indicated below for your 
state of residence.  No NSF fee will be charged if your state of residence is DE, MD, NE or WY.  If 
required by your state, you will receive a notice with instructions about the NSF service or collection 
fees, and if you fail to pay the fee we will add it to your account balance.  We are not required to 
present payment instruments more than once to the drawee for payment. This fee will be added 
to your account balance. 

MA, ME, AZ (greater of $10 or bank fee)

CA, MS, MO

CT, D.C., ID, IA, NJ, NY, OH, PA, UT, VT

AR, CO, FL, IL, IN, KY, LA, MI, MN, NV, NH, NM, NC, OK,  RI, TX, WI 

AL, AK, GA, HI, KS, MT, SC, SD, TN

ND, OR, VA, WA

*($25 maximum-first occurrence in more than 6 months.)  

$10

$15

$20

$25

$30*

$35*

13.  ACCOUNT  INFORMATION:    You  authorize  us  to  furnish  information  about  your  account  to 
credit reporting agencies and anyone else who may lawfully receive such information. On request, 
you agree to promptly provide us with accurate and updated financial and employment information. 
You agree to give us prompt notice of any change in your name, address, and telephone numbers. 
Where allowed by law, you authorize the Department of Motor Vehicles to release your address if 
it becomes necessary to locate you.

14. CHANGE IN TERMS:  We may change the terms of this Agreement, as permitted by law, at 
any time. You will be notified of changes in accordance with applicable state and federal law, but in 
the event your state does not specify a time period, you will be notified at least 45 days in advance 
of any such changes, and such notice will be sent to your current address as shown on our records 
for your account. We count the days from the date we mail the notification. 

15.  CREDIT  INVESTIGATION:    You  agree  we  may  investigate  your  credit,  employment,  and 
financial status. You authorize us to obtain a credit report and any other information about your 
creditworthiness  in  connection  with  processing  your  application  for  credit,  and  subsequently  in 
connection with any extension of credit, request to increase credit limits, or any renewal or update 
of your account, or to take collection action on the account, or to investigate disputes regarding 
the account. At your request, we will inform you if such reports were ordered, and the names of 
the credit bureaus that provided reports. You authorize the Department of Defense and its various 
departments and commands to verify your social security number or other identifier and disclose 
your  home  address  to  the  authorized  holder  of  this  Agreement  for  purposes  of  performing  or 
enforcing  the  terms  of  this  Agreement.  You  authorize  any  past  or  present  employer  to  confirm 
employment  or  communicate  with  us  regarding  your  indebtedness  to  us  if  you  fail  to  meet  the 
terms and  conditions  of this Agreement. We use information  furnished solely  in connection  with 
performing or enforcing the terms of this Agreement. 

20. REPRESENTATION:  You swear that all the information you supplied on your credit application 
and all the information on each revolving credit sales slip is and will be true, correct, and accurate. 
Any false, incorrect, or misleading information you knowingly supply is a deliberate misrepresentation. 
21.  STATE LAW RESIDENT NOTICES:
CALIFORNIA STATE NOTICE: Applicants may 1) use the credit account up 
to its credit limit after credit approval; 2) be liable for amounts extended under 
the plan to any joint applicant. A negative credit report reflecting on your credit 
record  may  be  submitted  to  a  credit  reporting  agency  if  you  fail  to  fulfill  the 
terms of your credit obligations.
COLORADO RESIDENTS: Warning: The terms of this revolving charge account may be changed, 
whether  or  not  authorized  by  agreement,  in  accordance  with  the  Colorado  UCCC  and  other 
applicable law.
DELAWARE:  Service  charges  not  in  excess  of  those  permitted  by  law  will  be  charged  on  the 
outstanding balances from month to month.
DISTRICT OF COLUMBIA: Seller certifies that the information contained in the contract complies 
with the District of Columbia Municipal Regulations, Title 16, Chapter 1.
ILLINOIS: No applicant may be denied a credit card on account of race, color, religion, national 
origin,  ancestry,  age  (between  40  and  70),  sex,  marital  status,  physical  or  mental  handicap 
unrelated to the ability to pay or unfavorable discharge from military service. The applicant may 
request the reason for rejection of his or her application for a credit card. No person need reapply 
for a credit card solely because of a change in marital status unless the change in marital status 
has caused deterioration in the person’s financial position. A person may hold a credit card in any 
name permitted by law that he or she regularly uses and is generally known by, so long as no fraud 
is intended thereby.
MAINE: We may request a consumer report in connection with your application for credit. You may 
ask whether a consumer report was obtained by us and we will tell you the name and address of 
the consumer reporting agency, if a report was obtained. Charges incurred by use of your card are 
due and payable on receipt of your monthly statement.
MARYLAND: Finance charges will be made in amounts or at rates not in excess of those permitted by 
law. You may pay the entire balance at any time without incurring additional charges for prepayment. 
NEW HAMPSHIRE: Consumer  or  Consumer’s  attorney  may file 
a complaint with the New Hampshire Commissioner of Banking.
VERMONT: We may obtain your credit reports at any time, for any legitimate purpose associated 
with the account or the application or request for an account, including but not limited to reviewing, 
modifying, renewing and collecting on your account. On your request we will inform you if such a 
report was ordered. If so, we will give you the name and address of the consumer reporting agency 
furnishing the report. 
OHIO:  Ohio  anti-discrimination  laws  require  creditors  to  make  credit  equally  available  to  all 
creditworthy  customers  and  that  credit  reporting  agencies  maintain  separate  credit  histories  on 
individuals upon request. The Ohio Civil Rights Commission administers these laws.
TEXAS: To contact Culligan Finance Company (a division of Aqua Finance, Inc.) about this account 
call 715-848-5425.  This contract is subject in whole or in part to Texas law which is enforced by the 
Consumer Credit Commissioner, 2601 N. Lamar Blvd., Austin, Texas 78705. Phone 512-936-7600. 
Contact the commissioner relative to any inquiries or complaints. 
22.   SECURITY AGREEMENT: You grant us a purchase money security interest under the Uniform 
Commercial Code in each household good purchased on account to the full extent permitted by 
law.  To the extent allowed by law, you will pay all official fees and taxes, and on request, take any 
reasonable action requested by us to preserve the collateral or to establish, determine priority of, 
perfect, continue perfected, terminate or enforce our interest in it or rights under this agreement. If 
you do not make payments as agreed, this security interest allows us to take actions in accordance 
with state laws governing the enforcement of security interests in collateral. You further agree to 
keep the goods installed at the address on the credit application and to not remove or materially 
alter them without our written consent. You may lose the goods you purchased if you do not meet 
your obligations under this agreement.

23. NOTICE:

ANY HOLDER OF THIS CONSUMER CREDIT CONTRACT IS SUBJECT 
TO  ALL  CLAIMS  AND  DEFENSES  WHICH  THE  DEBTOR  COULD 
ASSERT AGAINST THE SELLER OF GOODS OR SERVICES OBTAINED 
PURSUANT TO THIS AGREEMENT OR WITH THE PROCEEDS FROM IT.  
DEBTOR’S RECOVERY UNDER THIS AGREEMENT MAY NOT EXCEED 
THE AMOUNT OF CREDIT OUTSTANDING. 
CFC-AFI-500-RCA   1-1-2016   232726

Your Rights If You Are Dissatisfied With Your Credit Card Purchases  If 

you are dissatisfied with the goods or services that you have purchased with 

your credit card, and you have tried in good faith to correct the problem with the 

merchant, you may have the right not to pay the remaining amount due on the 

purchase.  To use this right, all of the following must be true:

1.  The purchase must have been in your home state or within 100 miles

of your current mailing address, and the purchase price must have

been more than $50.  (Note:  Neither of these are necessary if your

purchase was based on an advertisement we mailed to you, or if we

own the company that sold you the goods or services).

2.  You must have used your credit card for the purchase.  Purchases

  made with cash advances from an ATM or with a check that accesses

your credit card account do not qualify.

3.  You must not yet have fully paid for the purchase.

If all of the criteria above are met and you are still dissatisfied with the purchase, 

contact us in writing at:

Culligan Finance Company (a division of Aqua Finance, Inc.)

ATTN: Customer Billing

One Corporate Drive, Suite 300 

Wausau, WI 54401

While we investigate, the same rules apply to the disputed amount as discussed 

above.    After  we  finish  our  investigation,  we  will  tell  you  our  decision.    At  that 

point, if we think you owe an amount and you do not pay, we may report you as 

Note to all Buyers: Finance Charges will be made in amounts or at rates not 

in excess of those permitted by law.  You have the right to pay in advance 

the full amount due.

NOTICE  TO  BUYER:  1)  DO  NOT  SIGN  ANY  PART  OF  YOUR  REVOLVING 

CREDIT  AGREEMENT  BEFORE  YOU  READ  IT  OR  IF  IT  CONTAINS  ANY 

BLANK  SPACES.  2)  YOU  ARE  ENTITLED  TO  A  COMPLETELY  FILLED  IN 

COPY OF ANY AGREEMENT WHEN YOU SIGN IT. 3) A FINANCE CHARGE 

WILL  BE  COMPUTED  ON  THE  OUTSTANDING  BALANCE  EACH  BILLING 

PERIOD  IN  ACCORDANCE  WITH  THE  RATES  ABOVE.  4)  YOU  MAY  PAY 

YOUR TOTAL UNPAID BALANCE AT ANY TIME.

Dealer Name: _____________________________________________________ 

Address: _________________________________________________________

Arizona residents - You must give us notice of your claim or defense in writing by certified mail within 
90 days of receiving any goods or you may waive the right to set-offs or defense against assignee 
if assignee provides you a notice of your rights and you fail to exercise those rights pursuant to the 
terms of the notice.   Iowa residents - You must give assignee notice within 30 days of assignment 
to assert claims and defenses against assignee.   Oklahoma & South Dakota residents - You waive 
the right to bring a claim or defense against assignee if assignee provides you a notice of your rights 
and you fail to exercise those rights pursuant to the terms of the notice.   Wisconsin residents - You 
waive the right to bring a claim or defense against assignee after 12 months if assignee provides you 
a notice of your rights to do so and you fail to exercise those rights pursuant to the terms of the notice 
of assignment.  This waiver is in accordance with section 422.407 (4) of the Wisconsin Consumer 
Act.   Wyoming residents - You waive the right to bring a claim or defense against assignee for 45 
days after assignment if assignee provides you a notice of your rights and you fail to exercise those 
rights pursuant to the terms of the notice.
24.  CUSTOMER SERVICE:  Direct all inquiries concerning your account to: 
Culligan Finance Company (a division of Aqua Finance, Inc.)
P.O. Box 844
Wausau, WI 54402-0844
or call Customer Service at telephone number 800-234-3663.
25.  Aqua Finance, Inc. is not affiliated with Culligan International Company.
26:  BILLING RIGHTS NOTICE:  
Your Billing Rights: Keep this Document for Future Use
This notice tells you about your rights and our responsibilities under the
Fair Credit Billing Act.

What To Do If You Find A Mistake On Your Statement  

If you think there is an error on your statement write us at:  

Culligan Finance Company (a division of Aqua Finance, Inc.)

delinquent.

ATTN: Customer Billing

One Corporate Drive, Suite 300 

Wausau, WI 54401

In your letter, give us the following information:

•  Account Information: Your name and account number.

•  Dollar Amount: The dollar amount of the suspected error.

•  Description of Problem: If you think there is an error on your bill, 

describe what you believe is wrong and why you believe it is a mistake.

You must contact us: 

•  Within 60 days after the error appeared on your statement.  

•  At least 3 business days before an automated payment is scheduled if 

you want to stop payment on the amount you think is wrong.

You must notify us of any potential errors in writing. You may call us, but if you 
do we are not required to investigate any potential errors and you may have to 
pay the amount in question. 

What Will Happen After We Receive Your Letter
When we receive your letter, we must do two things: 
1. Within 30 days of receiving your letter, we must tell you that we received 
your letter. We will also tell you if we have already corrected the error.
2.  Within 90 days of receiving your letter, we must either correct the error or 
explain to you why we believe the bill is correct.
While we investigate whether or not there has been an error:

•  We cannot try to collect the amount in question, or report you as 

delinquent on that amount.

•  The charge in question may remain on your statement, and we may 

continue to charge you interest on that amount.

•  While you do not have to pay the amount in question, you are 

responsible for the remainder of your balance.

•  We can apply any unpaid amount against your credit limit.

After we finish our investigation, one of two things will happen:

• 

• 

If we made a mistake:  You will not have to pay the amount in 

question or any interest or other fees related to that amount.

If we did not believe there was a mistake: You will have to pay the 

amount in question along with applicable interest and fees. We will 

send you a statement of the amount you owe and the date payment 

is due.  We may then report you as delinquent if you do not pay the 

amount we think you owe.  

If you receive our explanation but still believe your bill is wrong, you may write to 
us within 10 days telling us that you still refuse to pay. If you do so, we cannot 
report you as delinquent without also reporting that you are questioning your bill.  
We must tell you the name of anyone to whom we reported you as delinquent, 
and  we  must  let  those  organizations  know  when  the  matter  has  been  settled 
between us. 
If we do not follow the rules above, we cannot collect the first $50 of the amount 
you questioned amount, even if your bill was correct.

CFC-AFI-500-RCA   1-1-2016   232726

Revolving Credit

Agreement

Revised 1-1-16

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
16. ACCOUNT CANCELLATION:  We may cancel your account at any time for any reason subject to 
the requirements of applicable law. Outstanding balances continue to accrue INTEREST CHARGES 
until paid in full, and remain subject to all terms and conditions of this Agreement. You may cancel 
your account by writing to our account service provider Culligan Finance Company (a division of Aqua 
Finance, Inc.), P.O. Box 844, Wausau, WI 54402-0844. Your notice is effective on receipt. If you cancel 

your Account, you are still responsible for all amounts owed pursuant to the terms of this Agreement. 

17. ASSIGNMENT:  This Agreement is not effective until your application has been approved by 
CFC. We have the right to assign any or all of our rights under this Agreement to any assignee of 
our choosing.  You may not assign this Agreement or any rights under it and any attempt to make 
such an assignment will be null and void. You understand that Dealer and CFC are independent 
entities and not employees or agents of one another. This Agreement legally binds the parties and 

their respective heirs, representatives, executors, administrators, successors and assigns.  

18. SEVERABILITY:  If any provision of this Agreement is deemed void or unenforceable under any 

law, rule, or regulation, all other provisions remain in effect and enforceable.

19. NON-WAIVER:  We do not lose any of our rights under this Agreement if we delay taking action 

for any reasons.

20. REPRESENTATION:  You swear that all the information you supplied on your credit application 
and all the information on each revolving credit sales slip is and will be true, correct, and accurate. 
Any false, incorrect, or misleading information you knowingly supply is a deliberate misrepresentation. 

21.  STATE LAW RESIDENT NOTICES:

CALIFORNIA STATE NOTICE: Applicants may 1) use the credit account up 
to its credit limit after credit approval; 2) be liable for amounts extended under 
the plan to any joint applicant. A negative credit report reflecting on your credit 
record  may  be  submitted  to  a  credit  reporting  agency  if  you  fail  to  fulfill  the 

terms of your credit obligations.

COLORADO RESIDENTS: Warning: The terms of this revolving charge account may be changed, 
whether  or  not  authorized  by  agreement,  in  accordance  with  the  Colorado  UCCC  and  other 

applicable law.

DELAWARE:  Service  charges  not  in  excess  of  those  permitted  by  law  will  be  charged  on  the 

outstanding balances from month to month.

DISTRICT OF COLUMBIA: Seller certifies that the information contained in the contract complies 

with the District of Columbia Municipal Regulations, Title 16, Chapter 1.

ILLINOIS: No applicant may be denied a credit card on account of race, color, religion, national 
origin,  ancestry,  age  (between  40  and  70),  sex,  marital  status,  physical  or  mental  handicap 
unrelated to the ability to pay or unfavorable discharge from military service. The applicant may 
request the reason for rejection of his or her application for a credit card. No person need reapply 
for a credit card solely because of a change in marital status unless the change in marital status 
has caused deterioration in the person’s financial position. A person may hold a credit card in any 
name permitted by law that he or she regularly uses and is generally known by, so long as no fraud 

is intended thereby.

MAINE: We may request a consumer report in connection with your application for credit. You may 
ask whether a consumer report was obtained by us and we will tell you the name and address of 
the consumer reporting agency, if a report was obtained. Charges incurred by use of your card are 

due and payable on receipt of your monthly statement.

MARYLAND: Finance charges will be made in amounts or at rates not in excess of those permitted by 
law. You may pay the entire balance at any time without incurring additional charges for prepayment. 
NEW HAMPSHIRE: Consumer  or Consumer’s  attorney  may  file 

a complaint with the New Hampshire Commissioner of Banking.

VERMONT: We may obtain your credit reports at any time, for any legitimate purpose associated 
with the account or the application or request for an account, including but not limited to reviewing, 
modifying, renewing and collecting on your account. On your request we will inform you if such a 
report was ordered. If so, we will give you the name and address of the consumer reporting agency 

furnishing the report. 

OHIO:  Ohio  anti-discrimination  laws  require  creditors  to  make  credit  equally  available  to  all 
creditworthy  customers  and  that  credit  reporting  agencies  maintain  separate  credit  histories  on 

individuals upon request. The Ohio Civil Rights Commission administers these laws.

TEXAS: To contact Culligan Finance Company (a division of Aqua Finance, Inc.) about this account 
call 715-848-5425.  This contract is subject in whole or in part to Texas law which is enforced by the 
Consumer Credit Commissioner, 2601 N. Lamar Blvd., Austin, Texas 78705. Phone 512-936-7600. 

Contact the commissioner relative to any inquiries or complaints. 

22.   SECURITY AGREEMENT: You grant us a purchase money security interest under the Uniform 
Commercial Code in each household good purchased on account to the full extent permitted by 
law.  To the extent allowed by law, you will pay all official fees and taxes, and on request, take any 
reasonable action requested by us to preserve the collateral or to establish, determine priority of, 
perfect, continue perfected, terminate or enforce our interest in it or rights under this agreement. If 
you do not make payments as agreed, this security interest allows us to take actions in accordance 
with state laws governing the enforcement of security interests in collateral. You further agree to 
keep the goods installed at the address on the credit application and to not remove or materially 
alter them without our written consent. You may lose the goods you purchased if you do not meet 

your obligations under this agreement.

23. NOTICE:

ANY HOLDER OF THIS CONSUMER CREDIT CONTRACT IS SUBJECT 

TO  ALL  CLAIMS  AND  DEFENSES  WHICH  THE  DEBTOR  COULD 

ASSERT AGAINST THE SELLER OF GOODS OR SERVICES OBTAINED 

PURSUANT TO THIS AGREEMENT OR WITH THE PROCEEDS FROM IT.  

DEBTOR’S RECOVERY UNDER THIS AGREEMENT MAY NOT EXCEED 

THE AMOUNT OF CREDIT OUTSTANDING. 

Arizona residents - You must give us notice of your claim or defense in writing by certified mail within 
90 days of receiving any goods or you may waive the right to set-offs or defense against assignee 
if assignee provides you a notice of your rights and you fail to exercise those rights pursuant to the 
terms of the notice.   Iowa residents - You must give assignee notice within 30 days of assignment 
to assert claims and defenses against assignee.   Oklahoma & South Dakota residents - You waive 
the right to bring a claim or defense against assignee if assignee provides you a notice of your rights 
and you fail to exercise those rights pursuant to the terms of the notice.   Wisconsin residents - You 
waive the right to bring a claim or defense against assignee after 12 months if assignee provides you 
a notice of your rights to do so and you fail to exercise those rights pursuant to the terms of the notice 
of assignment.  This waiver is in accordance with section 422.407 (4) of the Wisconsin Consumer 
Act.   Wyoming residents - You waive the right to bring a claim or defense against assignee for 45 
days after assignment if assignee provides you a notice of your rights and you fail to exercise those 
rights pursuant to the terms of the notice.
24.  CUSTOMER SERVICE:  Direct all inquiries concerning your account to: 
Culligan Finance Company (a division of Aqua Finance, Inc.)
P.O. Box 844
Wausau, WI 54402-0844
or call Customer Service at telephone number 800-234-3663.
25.  Aqua Finance, Inc. is not affiliated with Culligan International Company.
26:  BILLING RIGHTS NOTICE:  
Your Billing Rights: Keep this Document for Future Use
This notice tells you about your rights and our responsibilities under the
Fair Credit Billing Act.

What To Do If You Find A Mistake On Your Statement  

If you think there is an error on your statement write us at:  

Culligan Finance Company (a division of Aqua Finance, Inc.)
ATTN: Customer Billing
One Corporate Drive, Suite 300 
Wausau, WI 54401

In your letter, give us the following information:

•  Account Information: Your name and account number.
•  Dollar Amount: The dollar amount of the suspected error.
•  Description of Problem: If you think there is an error on your bill, 

describe what you believe is wrong and why you believe it is a mistake.

You must contact us: 

•  Within 60 days after the error appeared on your statement.  
•  At least 3 business days before an automated payment is scheduled if 

you want to stop payment on the amount you think is wrong.
You must notify us of any potential errors in writing. You may call us, but if you 
do we are not required to investigate any potential errors and you may have to 
pay the amount in question. 

Your Rights If You Are Dissatisfied With Your Credit Card Purchases  If 
you are dissatisfied with the goods or services that you have purchased with 
your credit card, and you have tried in good faith to correct the problem with the 
merchant, you may have the right not to pay the remaining amount due on the 
purchase.  To use this right, all of the following must be true:

1.  The purchase must have been in your home state or within 100 miles
of your current mailing address, and the purchase price must have
been more than $50.  (Note:  Neither of these are necessary if your
purchase was based on an advertisement we mailed to you, or if we
own the company that sold you the goods or services).

2.  You must have used your credit card for the purchase.  Purchases
  made with cash advances from an ATM or with a check that accesses

your credit card account do not qualify.

3.  You must not yet have fully paid for the purchase.

If all of the criteria above are met and you are still dissatisfied with the purchase, 
contact us in writing at:

Culligan Finance Company (a division of Aqua Finance, Inc.)
ATTN: Customer Billing
One Corporate Drive, Suite 300 
Wausau, WI 54401

While we investigate, the same rules apply to the disputed amount as discussed 
above.    After  we  finish  our  investigation,  we  will  tell  you  our  decision.    At  that 
point, if we think you owe an amount and you do not pay, we may report you as 
delinquent.

Note to all Buyers: Finance Charges will be made in amounts or at rates not 
in excess of those permitted by law.  You have the right to pay in advance 
the full amount due.

NOTICE  TO  BUYER:  1)  DO  NOT  SIGN  ANY  PART  OF  YOUR  REVOLVING 
CREDIT  AGREEMENT  BEFORE  YOU  READ  IT  OR  IF  IT  CONTAINS  ANY 
BLANK  SPACES.  2)  YOU  ARE  ENTITLED  TO  A  COMPLETELY  FILLED  IN 
COPY OF ANY AGREEMENT WHEN YOU SIGN IT. 3) A FINANCE CHARGE 
WILL  BE  COMPUTED  ON  THE  OUTSTANDING  BALANCE  EACH  BILLING 
PERIOD  IN  ACCORDANCE  WITH  THE  RATES  ABOVE.  4)  YOU  MAY  PAY 
YOUR TOTAL UNPAID BALANCE AT ANY TIME.

Dealer Name: _____________________________________________________ 

Address: _________________________________________________________

Revolving Credit

Agreement

What Will Happen After We Receive Your Letter
When we receive your letter, we must do two things: 
1. Within 30 days of receiving your letter, we must tell you that we received 
your letter. We will also tell you if we have already corrected the error.
2.  Within 90 days of receiving your letter, we must either correct the error or 
explain to you why we believe the bill is correct.
While we investigate whether or not there has been an error:

•  We cannot try to collect the amount in question, or report you as 

delinquent on that amount.

•  The charge in question may remain on your statement, and we may 

continue to charge you interest on that amount.

•  While you do not have to pay the amount in question, you are 

responsible for the remainder of your balance.

•  We can apply any unpaid amount against your credit limit.
After we finish our investigation, one of two things will happen:

• 

• 

If we made a mistake:  You will not have to pay the amount in 
question or any interest or other fees related to that amount.
If we did not believe there was a mistake: You will have to pay the 
amount in question along with applicable interest and fees. We will 
send you a statement of the amount you owe and the date payment 
is due.  We may then report you as delinquent if you do not pay the 
amount we think you owe.  

Revised 1-1-16

If you receive our explanation but still believe your bill is wrong, you may write to 
us within 10 days telling us that you still refuse to pay. If you do so, we cannot 
report you as delinquent without also reporting that you are questioning your bill.  
We must tell you the name of anyone to whom we reported you as delinquent, 
and  we  must  let  those  organizations  know  when  the  matter  has  been  settled 
between us. 
If we do not follow the rules above, we cannot collect the first $50 of the amount 
you questioned amount, even if your bill was correct.

CFC-AFI-500-RCA   1-1-2016   232726
CFC-AFI-500-RCA   1-1-2016   232726