[Firm Name] 401(k) PLAN

APPLICATION FOR LOAN

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Employer and Plan        Name of Plan:                                                                                      

Information                   Name of Employer:                                                                                            

Address:                                                                                                          

City:                                                      State:                Zip:                              

****************************************************************************** Applicant's Name:                                                                          SSN:                                                  

Address:                                                                                                                                                                                                                                                                                                          

County:                                                                                                                                               

Spouse's Name:                                                                                                                                   

Amount of Loan requested: $                                                                                                   

Length of Loan:             Years (Cannot exceed 5 years except for purchase of primary residence)

I hereby apply for a loan from the Plan. In support of this loan application, I attach such information which the administrator may require to determine whether I qualify for the loan, including financial statements and tax returns. I also authorize the Administrator to secure any credit reports to determine my credit-worthiness and ability to repay the loan.

In applying for this loan, I acknowledge that I have read the section of the Summary Plan Description governing Plan loans.

Applicant's Signature                                                    Spouse's Signature

Date                                                                             Date

Payments must be made on a bi-weekly basis.

******************************************************************************PLAN ADMINISTRATOR

This application is:         accepted           denied            

The interest rate to be charged is                        % annual interest

Plan Administrator's or Trustee's Signature