Consumer Loan Application

Mountain Valley Bank

Consumer Loan Application

Credit Application

Check the appropriate boxes and complete the applicable sections. Use

'NA' for blank fields.

Want to Repay Monthly?
YesNo

Proceeds of the Loan to be used for
SecuredUnsecured

Description of Collateral:

Section A

Individual Applicant Information

Do You
OwnRent

Do You
NAOwnRent

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.

Alimony, Child Support, or separate maintenance received under:
NACourt OrderWritten AgreementOral Understanding

Is any income listed in this Section likely to be reduced before the credit request is paid off?
NoYes

Have you previously received credit from us?
NoYes

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.

Alimony, Child Support, or separate maintenance received under:
NACourt OrderWritten AgreementOral Understanding

Is any income listed in this Section likely to be reduced before the credit request is paid off?
NoYes

Have you previously received credit from us?
NoYes

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.

APPLICANT
MarriedSeparatedUnmarried (including single, divorced or widowed)

OTHER PARTY
NAMarriedSeparatedUnmarried (including single, divorced or widowed)

Section D

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

Are you obligated to make Alimony, Support or Maintenance Payments?
NoYes

Are you a co-maker, endorser, or guarantor on any loan or contract?
NoYes

Are there any unsatisfied judgements against you?
NoYes

Have you been declared bankrupt in the last 10 years?
NoYes

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

Check One
We intend to apply for joint credit (Signatures Required Below)I am applying for credit in my name only, and am relying only on my income/assets in my name only for repayment of this loan.

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:

PLATTE VALLEY COMPANIES IDENTITY VERIFICATION

THE USA PATRIOT ACT REQUIRES THAT WE OBTAIN IDENTITY VERIFICATION FROM YOU BEFORE ESTABLISHING YOUR ACCOUNT.

MINIMUM INFORMATION REQUIRED:

NAME;

DATE OF BIRTH (FOR INDIVIDUALS);

ADDRESS

FOR INDIVIDUALS

RESIDENCE AND, IF DIFFERENT, MAILING ADDRESS;

FOR PERSONS OTHER THAN INDIVIDUALS (SUCH AS CORPORATIONS, PARTNERSHIPS AND TRUSTS)

PRINCIPAL PLACE OF BUSINESS AND, IF DIFFERENT, MAILING ADDRESS;

IDENTIFICATION NUMBER

U.S. PERSON

TAXPAYER IDENTIFICATION NUMBER (e.g. SOCIAL SECURITY NUMBER, INDIVIDUAL TAXPAYER IDENTIFICATION NUMBER OR EMPLOYER IDENTIFICATION NUMBER);

NON-U.S. PERSON

ONE OR MORE OF THE FOLLOWING: A U.S. TAXPAYER IDENTIFICATION NUMBER, PASSPORT NUMBER AND COUNTRY OF ISSUANCE; ALIEN IDENTIFICATION CARD NUMBER; OR NUMBER AND COUNTRY OF ISSUANCE OF ANY OTHER GOVERNMENT ISSUED DOCUMENT EVIDENCING NATIONALITY OR RESIDENCE AND BEARING A PHOTOGRAPH OR SIMILAR SAFEGUARD.

ADDITIONAL INFORMATION

IDENTIFICATION SUCH AS AN UNEXPIRED DRIVER’S LICENSE WITH A PHOTOGRAPH, EXCEPT THAT IF YOU ARE DISABLED, ELDERLY, OR A YOUTH WITHOUT A PHOTO IDENTIFICATION CARD, IDENTITY MAY BE VERIFIED BY A SOCIAL SECURITY, MEDICARE, MEDICAID OR OTHER INSURANCE CARD ALONG WITH A SEPARATE DOCUMENT THAT SHOWS YOUR NAME AND ADDRESS. (EACH JOINT SIGNER ON AN ACCOUNT WILL BE REQUIRED TO PROVIDE THIS INFORMATION WITHIN 30 DAYS. FAILURE TO PROVIDE INFORMATION WITHIN THIS TIME FRAME WILL RESULT IN SIGNATORY REVOCATION ON THE ACCOUNT).

ENTITIES OTHER THAN INDIVIDUALS WILL BE REQUIRED TO PROVIDE DOCUMENTS SHOWING THE EXISTENCE OF THE ENTITY SUCH AS FINANCIAL STATEMENTS, REGISTERED ARTICLES OF INCORPORATION, PARTNERSHIP AGREEMENTS OR TRUST INSTRUMENTS. (ADDITIONAL “MINIMUM” INFORMATION MAY BE REQUESTED FROM INDIVIDUALS WITH AUTHORITY OR CONTROL OVER SUCH ACCOUNTS AS THE BANK DEEMS NECESSARY).

Dated: September 2003

MOUNTAIN VALLEY BANK

Steamboat Springs - 970-870-6550
Meeker - 970-878-0103
Walden - 970-723-8221
Hayden - 970-276-9099
24hr Telebanking - 877-275-2088

Consumer Loan Application