VERIFIED STATEMENT OF NO MATERIAL CHANGE

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VERIFIED STATEMENT OF NO MATERIAL CHANGE Powered By Docstoc
					                           VERIFIED STATEMENT OF NO MATERIAL CHANGE




My name is ________________________________________. I am over eighteen years of age
                                               (First, Middle Initial, Last)

and I reside in ________________________________, _____________________. I have never
                                                      (City)                                (State)

been convicted of a crime, and I am fully competent to make this verified statement. I have

personal knowledge of the facts stated herein, and they are all true and correct.

My position is _________________________________________ at the applicant named below.
                                                           (Position/Title)

I certify that there has not been any material change in my financial condition since

_______________________, _______, the date of the last biographical and financial report
                (Month)                                  (Year)

submitted to the Colorado Division of Banking. Further, there has not been any other change

which would cause me to be ineligible to serve as a director and/or executive officer for the

applicant named below.



Signed this _______ day of ________________________, ______.
                      (Number)                                       (Month)       (Year)




                                                                     _______________________________________
                                                                                    Signature

                                                                     _______________________________________
                                                                               Print or Type Name

                                                                     _______________________________________
                                                                               Name of Applicant




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