Society of St. Vincent de Paul
Diocesan Council of Dallas

Micro Loan Program
Screening Interview Form


Name of person filling out form *

Email address of person filling out form *

Conference *    Interview date:

Applicant Name First *    Middle    Last *
Date of birth *    Gender *
Ethnicity * Hispanic or Latino
Non-Hispanic
Race *American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Address *Street    City    ZIP
County   (Dallas, Collin, Denton, Rockwell)
Email Address    Phone *   
Spouse Name    Marital Status *      
Email Address    Phone
Number in household

Employer *

1. Are you employed in a permanent (not seasonal/temporary) position with a steady paycheck?   

2. Is your income directly deposited to your bank account?   

3. Do you receive Social Security or a disability check?   

4. Are you willing to set up auto withdrawal for the new loan?   

5. How much do you owe the predatory lender or how much do you want to borrow for an emergency loan?

6. Total monthly (net) income:    Total monthly expenses:

    Monthly gross income: (from loan application)

7. Are you sure your completed budget form includes all of your monthly expenses?   

8. Are you interested in receiving budget counseling to find ways to reduce your
    your monthly expenditures if necessary?   

9. Do you normally keep a cushion for unexpected expenses like car repair and doctor bills?   

10 List predatory loans to be paid off. For emergency loan list payee and loan amount.

Loan company name *
Loan type * (Payday, Title, Emergency)
Current Balance: *
Monthly payment: *
APR: *

Loan Details
  Original loan date:
  Payment amount:
  Payment due date:
  How many payments have been made:
  Total paid to date:
  Notes:

Loan company name  
Loan type  
Current Balance:
Monthly payment:
APR:

Loan Details
  Original loan date:
  Payment amount:
  Payment due date:
  How many payments have been made:
  Total paid to date:
  Notes:

Loan company name  
Loan type  
Current Balance:
Monthly payment:
APR:

Loan Details
  Original loan date:
  Payment amount:
  Payment due date:
  How many payments have been made:
  Total paid to date:
  Notes:

Loan company name  
Loan type  
Current Balance:
Monthly payment:
APR:

Loan Details
  Original loan date:
  Payment amount:
  Payment due date:
  How many payments have been made:
  Total paid to date:
  Notes:

11. Original Loan amount(s) * Enter a list (1, 2, 3) - an original loan amount for each loan.

12. What caused you to take out the above loan(s)?


13. How much can you pay monthly on a proposed payoff loan?

14. Do you have transportation to set up a payoff loan?   

15. Bank selection * (Inwood, Legacy, Pegasus, Veritex)

If the loan is approved, the following information would be helpful:

Preferred branch location for loan signing

Preferred date and time for signing

Preferred day of the month for monthly payment

Comments: (Please use this area if there are more than 4 loans or for general comments.)