Shoshone Tribal Credit Office Online Loan Application
16 North Fork Rd
P.O. Box 398
Fort Washakie WY 82514
P: 307-332-2920
F: 307-335-8978

I would like to apply for a tribal loan in the amount specified below.
[Up to $350.00 if using Per Capita Withholding] or [Up to $500.00 if using Tribal Payroll Withholding]
for the purpose specified below; of which shall be advanced to me by check.
I will repay the loan on or before the dates below with interest and will execute a promissory note as evidence of the indebtedness. As security I will obligate my Shoshone Per Capita or Payroll Withholding.

DATE OF LOAN
MM
/
DD
/
YYYY
FIRST NAME
Your answer
LAST NAME
Your answer
PURPOSE OF LOAN
Do you currently have active loans?
EXPLAIN PURPOSE IF NEEDED
Your answer
DO YOU HAVE PROOF OF PURPOSE?
Loan Amount Specified
HOW WILL YOU BE PAYING BACK THE LOAN?
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