CONFIDENTIAL CS/NO.

1991

HAZINA SACCO SOCIETY LTD.

P.O. BOX 59877 - 00200 NAIROBI
TELEPHONE: (020) 2719098/2722106.MOBILE:0701820219/0701819685/0735926900/0712149631.
Kibera Road off Ngong Road E-mail: [email protected]/ [email protected]

LOAN APPLICATION & AGREEMENT FORM (Revised 2021)

LOAN REGISTRATION NO………………. DATE.......................................

A. REQUIREMENTS AND INSTRUCTIONS (Applicants must read the following before completing this form)
1. Applicants are required to be familiar with the Society’s current Credit Policy.
2. The applicant must ensure parts B - H are filled in full. Incomplete forms will be returned unconsidered.
3. The applicant is required to attach 2 months original current pay-slip (not more than two months old to the date of application)
and a copy of National ID card for every loan application. Original Log book, Title Deed & Fixed Deposit/Share deposit
statement, KRA PIN, 6 months bank statement where applicable.
4. All loans are processed as they are received.
5. All loans shall be disbursed through FOSA Accounts. To enable the Society Transfer your funds to your Bank account, indicate
your Bank Account Number, Name of Bank and Branch under section F.
6. In case your Loan is not recovered through the Payroll, please ensure that it’s paid by CASH, PAYBILL (850436)
promptly to avoid Interest in arrears, penalty and DEFAULT.
7. For Non check-off members, initiate standing order instructions ahead of disbursement.
8. For Private members and members who are on contract/temporary employment terms, attach guarantor consent form to the loan
application form.

B. PERSONAL INFORMATION
1. Member’s Full Name ………………………………............................................................................................................................
2. Member’s Current Address........................................................ ……………………………………………………………………...
3. Member’s Home Details: Address......................................................................................County …………………………………..
Sub-county………………….……………… Location…………………………Village....................................................................
Physical location (town/estate/street)…………………………………………………………………………………………………
4. Personal/Employment No.…………………………………………Membership/No. ........................................................................
5. Mobile No......................................Office Tel. No..................................Email....................................................................................
6. Employer/Ministry.................................................................................. Work Station........................................................................
7. Employer’s mailing address..................................................................................................................................................................
8. Terms of Employment - Permanent & Pensionable Contract Temporary Other …………………………………….
…………………………………….………………………(If Contract or Temporary attach copy of appointment letter)
9. For Private Members/Self Employed: Business Name /Nature of business (where applicable)
……………………………………………………………………………… Location……………………………………………….
10. Age ……………………………..ID No.................................................... KRA PIN............................................................................

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C. TYPE OF LOAN (Tick as appropriate)

BOSA Max 84 Max 72 Max 36 Max 24 Max 12 months

LOANS Months Months Months Months
SUPER NORMAL DARAJA JIBU SCHOOL COLLEGE EMERGENCY/ TECH LOAN
LOAN /TOP-UP LOAN LOAN FEES FEES TOP-UP

FOSA LOANS Max 48 Months Max 24 Months Max 12 Months

KARIBU LOAN HSF SPECIAL ADVANCE HSF OKOA
NOTE: All loans interest rate is on reducing balance.

D. LOAN AMOUNT
I (Full Name) ..........................................................................................................................hereby apply for a loan of
Kshs.......................... (Amount in Words) ............…………………………………………………………for a period
of....................months to be paid in installments of Kshs……………………… each month commencing immediately.

E. PURPOSE(S) FOR WHICH LOAN IS APPLIED (Please Tick where appropriate)

Restructured Agriculture Trade Manufacturing Education Human Land & Finance, Invest Consumption
loans Health Housing & Insurance & Social Act
Crop Wholesale & Cottage Loan For Medical Loan to To clear a Loan to buy
Farming Retail Industry education expenses buy Land micro finance utilities
loan
Animal Transport Servicing Building Loan to clear Loan to buy
Production Industry a house Bank loan consumables
Agriculture Hospitality Information Loan to buy a To buy
supporting Communication house consumer
activity Technology durables
Agri- Foreign Loan to buy
business Trade Insurance
Forestry Investment
&Logging

F. FOR FUNDS TRANSFER FROM FOSA.

(i) EFT/RTGS
Account Name. .......................................................................Account No

Bank Name.............................................................Branch....................................................................................................

(ii) Cheque Account Name. ...........................................................................................................................................

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G. APPLICANT’S DECLARATION (for Groups/Corporates - please sign as per your constitution)
I hereby declare that the foregoing particulars are true to the best of my knowledge and belief and agree to abide by the By-laws of
the Society, the Credit Policy and variations by the Credit Committee, I also consent to the Society checking, engaging and filing all the
information with the Credit Reference Bureau (CRB) and Debt Collection in respect of section D above. The security that I offer for
the loan is my salary, shares/deposits, guarantor’s shares/ deposits, acceptable collateral and any other benefits due to me from my
employer, from the Society (e.g. Dividends, Bonuses etc.). I authorize the necessary deductions, including interest at the current rate
be made from my salary as repayment for this loan. (Signature 2 & 3 are applicable for group & corporate)

SIGNATURE (1).................................................................... DATE........................................................................

SIGNATURE (2)……………………………………………. DATE………………………………………………..

SIGNATURE (3)…………………………………………… DATE………………………………………………..

WITNESSED BY (NAME) ...............................………………………………………………...MEMBER No. ......................

MOBILE ..............................................ADDRESS............................................................PERSONAL No.................................

SIGNATURE……………………………………………ID/No………………………….....Date...............................................

H. REPAYMENT GUARANTEE (To be completed by the guarantors who must be members of the Society)

We, the undersigned, hereby accept jointly and severally for the repayment of the loan balance, loan interest and any other cost
pertaining to the aforementioned loan of Kshs……………………. (amount in words:.…………………………………………………
………………………………………………..) in the event of the borrower’s default. We understand that the amount in default may
be recovered by an offset against our savings/deposits in the Society and/or by attachment of our property, salary and any other
benefits due to us from the Society (e.g. Dividends, Bonuses etc.) and that we shall not be eligible for loan(s) unless the amount in
default has been cleared in full.

(i) GUARANTORS

Personal/ Full Name ID No. Employer/ Amount Deposits Signature Witness Sign
Employment Ministry Guaranteed (Kshs) & Personal
No. (Kshs) No/
Member No

TOTAL

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 (ii) COLLATERAL
Title Deed
Title Name: Certified Value
Title No:
LR.No:
Confirmation of documents attached(sign): office

Log Book
Log book Name: Certified Value
Log book No:
Chassis No:
Engine No:
Confirmation of documents attached (sign):office

Shares/ Fixed deposits

CDS / FD Account No: Certified Value
Account Name:
No. of Shares
Value of shares
Fixed deposit amount
Confirmation of documents attached(sign):office
Note: Attach copy of collateral document, ID, KRA PIN & consent letter for jointly owned property.

I. EMPLOYER’S UNDERTAKING (To be completed by Management/HR)

On behalf of the employer / management ,we undertake to effect deductions for the loan applied and hereby confirm that the
application qualifies for the loan in line with the ruling payroll policy of one third deductions and further undertake to recover loan
defaulted from the employee’s benefits.
Name: …………………………………………………………………………………… Designation: ...........................................

Signature: ....................................................................... Date: ..........................................................................................................

FOR OFFICIAL USE ONLY

J. LOANS OFFICE
I certify that this loan application is within the Society’s current Loan Policy and I recommend it be approved for the amount of
Kshs…………………………. repayable in…………… installments at the rate of Kshs………………..………………per month.
Loan balance(s) Kshs........................................ Charges Kshs…………………………… Net Amount Kshs………………………

Comment(s)……………………………………………………………………………………………………………………………

Appraised by:

Loans Officer: Name ................................................................Signature...............................................Date........................................

Verified by:
Credit Manager: Name……………………………………………………Signature…………………………Date…………………..

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