Septic and Well Application

Region Five Development Commision
LOAN Application
TYPE OF LOAN: *
ISTS (Septic System) HWWS (Well Water)
APPLICANT(S) INFORMATION
Name: *
Home Phone: *
Date of birth: *
SSN: *
Cell Phone:
Address: *
City, State, Zip Code: *
Co-Applicant Name:
Home Phone:
Date of Birth:
SSN:
Cell Phone:
Address:
City, State, Zip Code:
Number of dependents living in the household: *
Email:
Address of property to be improved: *
County: *
EMPLOYMENT / INCOME INFORMATION
Applicant's current employer:
Address:
How long?
City:
State, Zip Code:
Position:
Annual income: *
Co-Applicant current employer:
Address:
How long?
City:
State, Zip Code:
Position:
Annual Income:
Other Income (Social Security, Child Support, Pension, etc) :
Other Income:
Other Income:
ASSETS (LIST ALL THAT APPLY)
Cash on Hand: *
Savings: *
IRA or Retirement Account: *
Real Estate: *
Real Estate:
Auto: *
Auto:
Auto:
Personal Property (list): *
Other Asset:
Other Asset:
Other Asset:
LIABILITIES - MONTHLY PAYMENTS
Mortgage: *
Are property taxes current? *
Y
N

Original Cost: *
Present Value: *
Balance Remaining: *
2nd Mortgage:
Line of Credit/Home Equity Loan:
Vehicle Loan: *
Vehicle Loan:
Vehicle Loan:
Installment loans:
Credit Card: *
Credit Card:
Credit Card:
Student Loan: *
Student Loan:
Other:
Other:
Other:
Please list additional information as needed:
Application Materials
Please email the following documents to svoigt*AT*regionfive.org in order to complete your application:
  • Signed AgBMP form (septic loans only) - AgBMP form is used by the State of MN to track, by county, who is using program.
  • Complete Legal Description of Property
  • Contractor’s Bid/Invoice (required)
  • Proof of income - YTD Pay Stub or tax return (required)
I certify that the above information is true and accurate to the best of my knowledge. I authorize representatives of Region Five to review my credit report and credit history to verify the accuracy of the statements made and to determine my creditworthiness. I authorize Region Five to contact my employer to verify employment or salary information. I authorize Region Five to discuss my application with county employees (environmental/planning & zoning) in which the septic system/water well will be repaired or replaced. I agree to pay a $50.00 application fee and it is included with this application. I understand that the intentional misrepresentation of facts may be the basis for a denial of credit.
Signature of applicant:
Date:
Signature of co-applicant, if for joint account:
Date:
I Accept *
By selecting the "I Accept" button, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application. Your electronic signature confirms that you have read and accepted the disclaimer above, and give permission to NCEDA to obtain information about your credit score.


County Contacts
Cass County - Dawn Berg
Environmental Services
218-547-7291
Crow Wing County – Tom Espersen
Planning & Zoning
218-824-1134
Morrison County-Amy Kowalzek
Planning & Zoning
320-632-0170
Todd County- Sarah Katterhagen
SWCD
320-732-2644
Wadena County-Deana Malone
Planning & Zoning
218-631-7604
Beltrami County-Bill Patnaude
Environmental Services
218-333-4158