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Statement of credit denial, termination or change

  • Date: 02/04/2025
  • Applicant Name:
  • Applicant Address:
  • Description of Action Taken: x Credit Denied Credit offered in lesser amount than requested Termination of Application by Applicant

Part I - Principal Reason(s) For Credit Denial, Termination, or Other Action Taken Concerning CreditThis section must be completed in all instances.

  • _____ Credit application incomplete
  • _____ Insufficient number of credit references provided
  • _____ Unacceptable type of credit references provided
  • _____ Unable to verify credit references
  • _____ Temporary or irregular employment
  • _____ Unable to verify employment
  • _____ Length of employment
  • _____ Income insufficient for amount of credit requested
  • _____ Excessive obligations in relation to income
  • _____ Unable to verify income
  • _____ Length of residence
  • _____ Temporary residence
  • _____ Unable to verify residence
  • _____ No credit file
  • _____ No Limited credit experience
  • _____ Poor credit performance with us
  • _____ Delinquent past or present credit obligations with others
  • _____ Collection action or judgement
  • _____ Garnishment or attachment
  • _____ Foreclosure or repossession
  • _____ Bankruptcy
  • _____ Number of recent inquiries on credit bureau report
  • _____ Other, specify:
  • _____ The information you provided in your application did not score a sufficient number of points for approval of your application. The reasons you did not score well compared to other applicants were:
    1.
    2.
    3.

Part II - Disclosure of Use of Information Obtained from an Outside SourceThis section should be completed if the credit decision was based in whole or in part on information that has been obtained from an outside source.

_____ Our credit decision was based in whole or in part on information obtained in a report from the consumer reporting agency listed below. You have a right under the Fair Credit Reporting Act to know the information contained in your credit file at the consumer reporting agency. The reporting agency played no part in our decision and is unable to supply specific reasons why we have denied credit to you. You also have a right to a free copy of your report from the reporting agency, if you request it no later than 60 days after you receive this notice. In addition, if you find that any information contained in the report you receive is inaccurate or incomplete, you have the right to dispute the matter with the reporting agency.

Name:
Address:
Toll-free Telephone Number:
Name:
Address:
Toll-free Telephone Number:

We also obtained your credit score from this consumer reporting agency and used it in making our credit decision. Your credit score is a number that reflects the information in your consumer report. Your credit score can change, depending on how the information in your consumer report changes.

Risk Scoring System Name:
Your credit score:
Date:
Scores range from a low of _________________ to a high of _________________
Key factors that adversely affected your credit score:
1.
2.
3.

If you have any questions regarding your credit score, you should contact ____________________ at:

Address: ____________________
Toll-free Telephone Number: ____________________

_____ Our credit decision was based in whole or in part on information obtained from an affiliate or from an outside source other than a consumer reporting agency. Under the Fair Credit Reporting Act, you have the right to make a written request, no later than 60 days after you receive this notice, for disclosure of the nature of this information.

If you have any questions regarding your credit score, you should contact:
Creditor's Name:
Creditor's Address:
Creditor's telephone number:

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 that 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 this law concerning this creditor is the Federal Trade Commission, Equal Credit Opportunity, Washington, DC 20580.

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