Bank Reference

"*" indicates required fields

The undersigned hereby authorizes the following information to be released to Gene Lilly Surety Bonds:

Today's Date*

By*

Re:*

To:*

Address of Bank*

Street Address Address Line 2 City State ZIP Code

We have written or been asked to consider writing bonds for the above and your bank has been given as a reference. Please provide the following information:

1. How long has the above been with your bank?*

2. Approximate average cash balance last six (6) months:*

Have there been over drafts?*

Floats?*

Returned Checks?*

3. General credit experience:*

What security was pledged?*

4. Is there an established line of credit?*

Expiration Date*

What is the gross amount overall?*

How much is currently in use?*

How is the line secured?*

5. Are all loans current?*

6. Have any loans been restructured to avoid delinquincy?*

7. Additional Comments*

Prepared by:*

First Last

Title*

Today's Date*

Phone*

Email*

Name

This field is for validation purposes and should be left unchanged.

Bank Reference

Bank Reference

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