Credit Card Application

VARIABLE RATE

(See back panel for rate information)

Platinum Elite Visa®
Platinum Elite Rewards Visa® 
Platinum Elite Cash Back Visa® 
Secured Classic Visa® 

ACCOUNT
TYPE

INDIVIDUAL

JOINT

CREDIT UNION
ACCOUNT NUMBER

APPLICANT
If you are applying for credit in your own name, complete Applicant portion only.

CO-APPLICANT
Co-Applicant / Co-signer / Guarantor, must complete Co-Applicant side.

NAME - LAST 

FIRST 

M.I.

NAME - LAST 

FIRST 

M.I.

HOME ADDRESS - STREET

HOW LONG

HOME ADDRESS - STREET

HOW LONG

CITY 

STATE 

ZIP CODE

CITY 

STATE 

ZIP CODE

HOME PHONE

BUSINESS PHONE

HOME PHONE

BUSINESS PHONE

DATE OF BIRTH

SOCIAL SECURITY NO.

DATE OF BIRTH

SOCIAL SECURITY NO.

EMPLOYER

DATE HIRED

EMPLOYER

DATE HIRED

POSITION OR JOB TITLE

GROSS MONTHLY PAY
$

POSITION OR JOB TITLE

GROSS MONTHLY PAY
$

PREVIOUS EMPLOYER IF LESS THAN 2 YEARS

HOW LONG

PREVIOUS EMPLOYER IF LESS THAN 2 YEARS

HOW LONG

HOME

OWN 

RENT

MONTHLY PAYMENT
$

NOTE 

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 loan.

SOURCE OR KIND

OTHER
INCOME

PAYOR

PLEASE ISSUE VISA®
CARD(S) EMBOSSED WITH EACH
NAME PRINTED HERE

MONTHLY AMOUNT
$
IS INCOME LIKELY
TO BE REDUCED
IN 2 YEARS?
1. PLEASE PRINT

YES 

SOURCE OR KIND

OTHER
INCOME

PAYOR

NO

2. PLEASE PRINT

MONTHLY AMOUNT
$
IS INCOME LIKELY
TO BE REDUCED
IN 2 YEARS?

YES 

NO

NUMBER OF
CARDS DESIRED

TRANSFER
AUTHORIZATION —
I WANT TO TRANSFER
THE CREDIT CARD
ACCOUNT(S) SHOWN
TO MY NEW LAKE TRUST 
CREDIT UNION 
ACCOUNT. THESE 
TRANSFERS WILL 
BE TREATED AS A 
CASH ADVANCE. 

1 

2 

3

1. CARD ISSUER

ADDRESS — STREET

2. CARD ISSUER

NOTE

IF YOU ARE REQUESTING A LINE OF
CREDIT INCREASE, PROVIDE YOUR
VISA ACCOUNT NUMBER

ACCOUNT NO.

BALANCE TO TRANSFER

CITY 

STATE 

ZIP CODE

TELEPHONE NO.

ACCOUNT NO.

BALANCE TO TRANSFER

ADDRESS — STREET

CITY 

STATE 

ZIP CODE

TELEPHONE NO.

OPTIONAL LOAN PROTECTION INFORMATION (NOT REQUIRED FOR APPROVAL)

CHECK OPTION DESIRED. A SEPARATE DOCUMENT WHICH DISCLOSES THE TERMS AND CONDITIONS MUST BE SIGNED FOR COVERAGE TO BECOME EFFECTIVE.
Would you like Lake Trust Loan Protection?
Would you like Lake Trust Loan Protection Plus?
No Protection

___________ Initial
___________ Initial
___________ Initial

IF YOU CHECKED YES ABOVE, YOU WILL RECEIVE ADDITIONAL INFORMATION AND FORM(S) TO SIGN THAT WILL INITIATE COVERAGE.

This statement is submitted to obtain credit and I (we) certify  that all information herein is true and complete. I (We) also authorized Lake Trust Credit Union to verify or obtain further information the Credit Union may 
deem necessary concerning my (our) credit standing. If this application is approved and a Visa® issued, the undersigned applicant(s) by signing, using, or permitting another to use the Visa® card(s) agree(s) that the 
applicant(s) will be bound by the terms and conditions accompanying the Visa® and all amendments. By signing an application you are also granting a security interest in any present and future share or deposit 
accounts in the credit union in which you have an interest excepting those accounts that would have an adverse tax consequence. You understand that by signing you are giving the credit union a consensual lien on 
your shares and other accounts. You understand granting a security interest is a condition for the credit card account and you give Lake Trust Credit Union a security interest in all funds now or hereafter in all of my 
deposit accounts (except IRA), and if I default under the terms of this agreement I authorize you to apply such funds to the payment of my credit card indebtedness.

FOR SECURED VISA ONLY

I/We agree to give the Lake Trust Credit Union a security interest in the following share deposit account: __________________________________________________________________________ I/We have in the Lake Trust 
Credit Union as a condition of obtaining credit under the Secured Visa® credit card. I/We understand that the Visa® will be secured by shares equal to 110% of the credit line approved for the duration of the loan, 
regardless of the outstanding Visa® balance.
I/We agree that the Lake Trust Credit Union may withdraw money from the share deposit account to pay any amount that is due twenty-five (25) days after my/our monthly statement closing date.

APPLICANT SIGNATURE

DATE

CO-APPLICANT/CO-SIGNER/GUARANTOR SIGNATURE

DATE

X

X

CREDIT UNION USE ONLY

APPROVED

DENIED

COUNTER
OFFER

(SPECIFY)

VISA
LINE OF
CREDIT LIMIT

LOAN OFFICER SIGNATURE 

DATE

REASONS FOR DENIAL/COUNTER OFFER

SEE BACK PANEL FOR CREDIT TERMS

Interest Rates and Interest Charges
Annual Percentage Rate (APR) for
Purchases

APPLICATION AND
SOLICITATION
DISCLOSURE

Platinum Elite Visa

,

,

,

,
when you open your account, based on your creditworthiness. This APR will
vary with the market based on the Prime Rate.

or

Platinum Elite Rewards Visa

,
when you open your account, based on your creditworthiness. This APR will
vary with the market based on the Prime Rate.

or

Platinum Elite Cash Back Visa

,
when you open your account, based on your creditworthiness. This APR will
vary with the market based on the Prime Rate.

or

,

,

,

,

,

,

Secured Classic Visa

This APR will vary with the market based on the Prime Rate.

APR for Balance Transfers

Platinum Elite Visa

,

or
account, based on your creditworthiness. This APR will vary with the market
based on the Prime Rate.

, when you open your

,

,

Platinum Elite Rewards Visa

,

or
account, based on your creditworthiness. This APR will vary with the market
based on the Prime Rate.

, when you open your

,

,

Platinum Elite Cash Back Visa

,

or
account, based on your creditworthiness. This APR will vary with the market
based on the Prime Rate.

, when you open your

,

,

Secured Classic Visa

This APR will vary with the market based on the Prime Rate.

© CUNA Mutual Group 2009, 10, 12, 16 All Rights Reserved

02101376-MXC10-P-1-061417 (MXC101-E)

SEE NEXT PAGE for more important information about your account.

APR for Cash Advances

Platinum Elite Visa

,

or
account, based on your creditworthiness. This APR will vary with the market
based on the Prime Rate.

, when you open your

,

,

Platinum Elite Rewards Visa

,

or
account, based on your creditworthiness. This APR will vary with the market
based on the Prime Rate.

, when you open your

,

,

Platinum Elite Cash Back Visa

,

or
account, based on your creditworthiness. This APR will vary with the market
based on the Prime Rate.

, when you open your

,

,

Secured Classic Visa

How to Avoid Paying Interest on
Purchases

This APR will vary with the market based on the Prime Rate.

Your due date is at least 25 days after the close of each billing cycle. We will
not charge you any interest on purchases if you pay your entire balance by
the due date each month.

For Credit Card Tips from the
Consumer Financial Protection Bureau

To learn more about factors to consider when applying for or using a
credit card, visit the website of the Consumer Financial Protection
Bureau at http://www.consumerfinance.gov/learnmore.

Fees
Annual Fee
- Annual Fee

Transaction Fees
- Foreign Transaction Fee

Penalty Fees
- Late Payment Fee
- Returned Payment Fee

None

1.00% of each transaction in U.S. dollars

Up to $35.00
Up to $25.00

How We Will Calculate Your Balance:
We use a method called "average daily balance (including new purchases)."

Effective Date:
The information about the costs of the card described in this application is accurate as of:
This information may have changed after that date. To find out what may have changed, contact the Credit Union.

For California Borrowers, the Platinum Elite Visa, Platinum Elite Rewards Visa, Platinum Elite Cash Back Visa and
Secured Classic Visa are secured credit cards. Credit extended under this credit card account is secured by
various personal property and money including, but not limited to: (a) any goods you purchase with this account,
(b) any shares you specifically pledge as collateral for this account on a separate Pledge of Shares, (c) all shares
you have in any individual or joint account with the Credit Union excluding shares in an Individual Retirement
Account or in any other account that would lose special tax treatment under state or federal law, and (d)
collateral securing other loans you have with the Credit Union excluding dwellings. Notwithstanding the
foregoing, you acknowledge and agree that during any periods when you are a covered borrower under the
Military Lending Act your credit card will be secured by any specific Pledge of Shares you grant us but will not be
secured by all shares you have in any individual or joint account with the Credit Union. For clarity, you will not be
deemed a covered borrower if: (i) you establish your credit card account when you are not a covered borrower;
or (ii) you cease to be a covered borrower.

© CUNA Mutual Group 2009, 10, 12, 16 All Rights Reserved

02101376-MXC10-P-1-061417 (MXC101-E)

SEE NEXT PAGE for more important information about your account.

Other Fees & Disclosures:
Late Payment Fee:
$25.00 or the amount of the required minimum payment, whichever is less, if you are one or more days late in making a
payment. In the event you fail to make a payment on time in any of the six billing cycles following the initial violation, you
will be charged $35.00 or the amount of the required minimum payment, whichever is less.

Returned Payment Fee:
$25.00 or the amount of the required minimum payment, whichever is less.

Card Replacement Fee:
$25.00.

Rush Fee:
$20.00.

Statement Copy Fee:
$2.00.

Research Fee:
$20.00 minimum per hour.

Sales Draft Copy Fee:
$5.00 per copy.

Stop Payment Fee:
$28.00 per request.

© CUNA Mutual Group 2009, 10, 12, 16 All Rights Reserved

02101376-MXC10-P-1-061417 (MXC101-E)