Consumer Loan Application

Description of Collateral:

Section A

Individual Applicant Information

Other Income

Note: Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.

Section B

Joint Applicant or Other Party Information. Complete only if: for joint credit, for individual credit relying on income or assets from other sources or applicant is married and resides in a community property state.

Other Income

Note: Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.

Section C

Marital Status Note: Complete only if for joint or secured credit, or applicant resides in a community property state or is relying on property located in such a state as a basis for repayment of the credit requested.

Section D

Complete the following information about both the Applicant and Joint Applicant or Other Person (if applicable).

Section E - Insurance

Mountain Valley Bank (Lender) is hereby authorized to contact, discuss with and request from my/our Insurance Agency listed below as loss payee on insurance policies covering collateral pledged to Lender to secure indebtedness currently owed by me/us.

Section F - Bank Location

So we can better serve you, please select the Mountain Valley Bank location that you bank at or the location nearest you.

NOTICE - Joint Intent

Signatures

I certify that everything I have stated in this application and on any attachments is correct. Lender may keep this application whether or not it is moved. By signing below I authorize Lender to check my credit and employment history and to answer questions others may ask Lender about my credit record with Lender. I understand that I must update credit information at Lender's request if my financial condition changes.

Consumer Credit Disclosure

This document is a written disclosure for the sale of insurance when Mountain Valley Bank extends credit.

To Credit Applicant

Mountain Valley Bank advised you we may not condition the extension of credit on the following:
-Your purchase of insurance from Mountain Valley or any of its affiliates;
-Your agreement to not obtain insurance from an entity not affiliated with Mountain Valley Bank.

In addition, Mountain Valley Bank may not prohibit you from obtaining insurance from an entity not affiliated with us.

Please sign to acknowledge the written and verbal receipt of this disclosure: