Member FDIC 800 758-1741 * Toll Free Fax 866 358-6018 * 133 Main Street * PO Box 98 * Hulett, WY 82720 www.summitnb.com Real Estate Loan Applicant: Due to the Patriot Act and our bank policies, we are required to collect certain information from you in order to consider your loan. In addition to the loan forms, we will need the following: Proof of Income: Include copies of your last three (3) years of income tax returns. Proof of Physical Address: Include a copy of a form that has your physical address on it (i.e. electric bill). Proof of Tax Identification: Include a copy of your Social Security Card. Proof of Identification by Government issued Picture ID: Include a copy of your Drivers License, State ID, or Military ID. If you have any questions while preparing these documents, feel free to call us. Thank-you for applying for a loan with Summit National Bank. Updated 02/02/10. 21b468e2-e2bb-495c-8140-5d31194a573e.xls Real Estate Loan Application Page 2 of 3 REAL ESTATE LOAN CREDIT APPLICATION 1. TYPE OF MORTGAGE AND TERMS OF LOAN Mortgage Applied for: Amount: Interest Rate: No. of Months: Monthly Payment Escrow (collected monthly): Conventional Principle & Interest Taxes Hazard Ins. Other Other 2. PROPERTY INFORMATION AND PURPOSE OF LOAN Property Street Address City County State Zip No. Units Legal Description (Attach description if necessary) Loan Purpose: Purchase Construction-Permanent Construction Refinance Other (Explain) Complete this line if Construction- LOT DATA VALUE: Original Cost Present Value (a) Cost of Improvements (b) Total Permanent or Construction Loan Year Acquired Amt. Existing Purpose of Refinance Describe Improvements made to be made Complete this line Year Acquired Original Cost Liens if Refinance Loan Cost: Title will be held in what name(s): Manner in which title will be held: Source of Down Payment and Settlement Charges: This application is designed to be completed by the borrower(s) with the lender’s assistance. The Co-Applicant Section and all other Co-Applicant questions must be completed and the appropriate box(es) checked. If another person will be jointly obligated with the Applicant on this loan, or the Applicant is relying on income from alimony, child support or separate maintenance, or on the income or assets of another person as a basis for repayment of the loan, or the Applicant is married and resides, or the property is located in a community property state. Applicant 3. APPLICANT INFORMATION Co-Applicant Name (include Jr. or Sr. if applicable) Name (include Jr. or Sr. if applicable) Social Security No. Home Phone Date of Birth Yrs. School Social Security No. Home Phone Date of Birth Yrs. School Married Separated Dependents (not listed by Co-App) Married Separated Dependents (not listed by App) Unmarried (Explain) No./Age Unmarried (Explain) No./Age Address (street, city, state, zip) Rent Own No. Years Address (street,city,state,zip) Rent Own No. Years Applicant 4. EMPLOYMENT INFORMATION Co-Applicant Name & Address of Employer Self Employed* Name & Address of Employer Self Employed* Yrs on Job: Yrs on Job: Yrs. In this line of work or profession: Yrs. In this line of work or profession: Position/Title/Type of Business Business Phone Position/Title/Type of Business Business Phone If employed in current position for less than two years or if currently employed in more than one position, complete the following: A - Applicant C Previous Employer City/State Type of Business Position/Title Dates From/To Monthly Income - CoApp * Self Employed Borrower(s) may be required to provide additional documentation such as tax returns and financial statements. 5. GROSS MONTHLY INCOME 5B. MONTHLY HOUSING EXPENSE Item Applicant Co-Applicant Total Item Present Proposed DO NOT COMPLETE IF REFINANCE Base Empl. Inc. Rent Purchase Price Overtime First Mort (P&I) Closing Costs (est.) Bonuses Other Financing (P&I) Prepaid Escrow (est.) Commissions Hazard Insurance Total Dividends/Interst Real Estate Taxes Amount this Mortgage Net Rental Inc. Mortgage Insurance Other Financing Other** Homeowner Dues Other Equity Other Amount of Cash Dep Total Seller Concession Utilities Cash at Closing Total Total ** Alimony, child support, or separate maintenance income need not be revealed if the Applicant or Co-Applicant does not choose to have it considered as a basis for repaying this loan. Real Estate Loan Application Page 2 of 3 6. DECLARATIONS If you answer Yes (Y) to any question a through I, please use continuation sheet for explanation. Applicant Co-Applicant a. Are there any outstanding judgments against you? b. Have you been declared bankrupt within the past 7 years? c. Have you had property foreclosed upon or given title or deed in lieu thereof in the last 7 years? d. Are you a party to a law suit? e. Have you directly or indirectly been obligated on any loan which resulted in foreclosure, transfer of title in lieu of foreclosure, or judgment? f. Are you presently delinquent or in default on any Federal debt or any other loan, mortgage, financial obligation, bond or loan guarantee? g. Are you obligated to pay alimony, child support, or separate maintenance? h. Is any part of the down payment borrowed? i. Are you a co-maker or endorser on a note? 7. ASSETS AND LIABILITIES This statement and any applicable supporting schedules may be completed jointly by both married and unmarried co-applicants if their assets and liabilitie are sufficiently joined so that the Statement can be meaningfully and fairly presented on a combinded basis; otherwise separate Statements and schedules are required. If the co-applicant section was completed about a spouse, this statement and supporting schedules must be compelted about the spouse also. Completed Jointly Not Completed Jointly Cash or Liabilities and Pledged Assets. List the creditor's name, address, and account number for all outstanding ASSETS Market Value debts including automobile loans, revolving charge accounts, real estate loans, alimony, child support, stock Cash deposit toward purchase held by: pledges, etc. Use continuation sheet if necessary. Indicate by (*) those liabilities or pledged assets which will be satisfied upon sale of real estate owned or upon refinancing of subject property. Monthly Paments & Months List checking and savings accounts below LIABILTITES Unpaid Balance to Pay Name and address of Bank, S&L, or Credit Union Name and address of Company Acct No. Acct No. Name and address of Bank, S&L, or Credit Union Name and address of Company Acct No. Acct No. Name and address of Bank, S&L, or Credit Union Name and address of Company Acct No. Acct No. Stock and Bonds (Co Name, number & desc.) Name and address of Company Acct No. Life Insurance Name and address of Company Net Cash Value Face Amount Acct No. Subtotal Liquid Assets Name and address of Company Real Estate (from Schedule of RE Owned) Vested interest in retirement fund Acct No. Net Worth of business(es) owned* Alimony/Child Support/Separate Maintenance Payments Automobiles owned (make and model) Owed to: Other Assets (Itemize) Job-Related Expenses (child care, union dues, etc.) Total Monthly Payments Total Assets (a.) Net Worth Total Liabilities (b.) Real Estate Loan Application Page 2 of 3 SCHEDULE OF REAL ESTATE OWNED (If additional properties owned attach separate schedule) Address of Property (indicate S-Sold, PS-Pending Amount of Taxes, Ins, Maintenance & Type of Gross Rental Present Market Value Morgages & Net Rental Income Sale, or R-Rental held for income) Property Income Misc. Liens TOTALS List additional names under which credit has previously been received and indicate appropriate creditor name(s) and account number(s): Name Creditor Acct# 1. 2. 8. ACKNOWLEDGEMENT AND AGREEMENT NOTICE - JOINT CREDIT if this is an application for joint credit, Applicant and Co-Applicant each agree to apply for joint credit. __________ __________ BLANKET AUTHORIZATION I certify that everything stated in this application and on my attachments is true and correct. I hav emade no misrepresentations in this application or with other documents, nor did I omit any pertinent information. I have applied for the loan indicated in this application to be secured by a first mortgage or deed of trust on the property descrived herein, and represent that the property will not be used for any illegal or restricted purpose. I fully understand that it is a Federal crime to knowingly make any false statements when applying for a loan. The Lender amy keep this application whether or not it is approved. I hereby five my consent for information contained in this loan application or in other documents required in connection with the loan, either before the loan is closed or as part of its quality control program, to be verified or re-verified. This verification/re- verification may be made by SUMMIT NATIONAL BANK, its agents, successors, and assigns either directly or through a credit reporting agency. I understand that I must update credit inforamtion at Lender's request if my financial condition changes. FEDERAL CREDIT APPLICATION INSURANCE DISCLOSURE I have applied for an extension of credit with you. You are soliciting, offering, or selling me an insurance product or annuity in connection with this extension of credit. FEDERAL LAW PROHIBITS YOU FROM CONDITIONING EXTENSION OF CREDIT ON EITHER: (1) My purchase of an insurance product or annuity from you or from your affiliates; or (2) My agreement not to obtain, or a prohibition on me from obtaining, an insurance product or annuity from an unaffiliated entity. By signing, I acknowledge that I have read and understand both the Blanket Authorization and the Federal Credit Application Insurance Disclosure. Applicant's Signature Date Co-Applicant's Signature Date 9. INFORMATION FOR GOVERNMENT MONITORING PURPOSES The following information is requested by the Federal Government for certain types of loans related to a dwelling in order to monitor the lender's compliance with equal credit opportunity, fair housing and home mortgage disclosure laws. You are not required to furnish this inforamtion, but are encouraged to do so. The law provides that a lender may not discriminate either on basis of this information, or on whether you choose to furnish it. If you furnish the information, please provide both ethnicity and race. For race, you may check more than one designation. if you do not furnish ethnicity, race, or sex, under Federal regulations, this lender is required to note the information on the basis of visual ovservation and suname if you have made this application in person. If you do not wish to furnish the information, please check the box below. (Lender must review and approve material to assure that the disclosures satisfy all requirements to which the lender is subject under applicable state law for the particular type of loan applied for.) APPLICANT I do not wish to furnish this information APPLICANT I do not wish to furnish this information Ethnicity Hispanic or Latino Not Hispanic or Latino Ethnicity Hispanic or Latino Not Hispanic or Latino Native Hawaiian or Other Pacific Highlander Native Hawaiian or Other Pacific Highlander American Indian or Alaska Native American Indian or Alaska Native Race Race Asian Asian Black or African American Black or African American White White White Sex Female Male Sex Female Male 10. TO BE COMPLETED BY INTERVIEWER This application was taken by: Name and Address of Interviewer's Employer face to face interview Summit National Bank by telephone Interviewer's Name (print or type) Phone number PO Box 98 by mail 133 Main by internet Signature Date Hulett, Wy 82720 Member FDIC 800 758-1741 * Toll Free Fax 866 358-6018 * 133 Main Street * PO Box 98 * Hulett, WY 82720 www.summitnb.com Cash Flow Worksheet Name: Phone: Name: Phone: Loan Purpose: MONTHLY BUDGET Income Item 1. Net Income (take home, include spouse) 2. Interest/Dividends 3. Support Payments Received 4. Other Income + Loan Payments 1. Rent or Mortgage 2. Auto Payments, # 3. Loan Payments - This Bank 4. Credit Card Payments 5. All Other Loan Payments - Other Fixed Payments 1. Utilities (H-L-G), etc. 2. Support Payments 3. Other Fixed Payments - Discretionary Expenses 1. Food 2. Auto Expenses (insurance, gas, etc) 3. Clothing/Household Goods 4. Insurance - Life, Home, etc. 5. All Others - Total Funds Remaining (Cash Flow) Signature Date Signature Date Member FDIC 800 758-1741 * Toll Free Fax 866 358-6018 * 133 Main Street * PO Box 98 * Hulett, WY 82720 www.summitnb.com Agreement to Pay Loan Processing Expenses By signing below, I understand there are expenses associated with processing this loan. I agree to pay all processing expenses even if the loan applied for is denied or withdrawn. Applicant Date Co-applicant Date Member FDIC 800 758-1741 * Toll Free Fax 866 358-6018 * 133 Main Street * PO Box 98 * Hulett, WY 82720 www.summitnb.com We offer Credit Life Insurance and Disability Coverage! Credit Life Insurance The following products are available with your loan (single or joint): * GROSS PAY LIFE – Insurance coverage equal to the total of payments * NET PAY LIFE – Insurance coverage equal to the amount financed * DECREASING LIFE – Coverage decreases commensurate with the payment schedule * LEVEL LIFE COVERAGE – Coverage stays the same for the term of the loan Disability The following products are available for a single or joint loan that is setup with regular installment payments (monthly, quarterly, etc.): * 7 DAY RETRO AND 14 DAY RETRO – Full Term customer has to be off for either (7) or (14) days, depending on plan chosen, to file for benefits – once qualified coverage goes back to the first day of disability * 30 DAY ELIMINATION – Full Term – the first 30 days of disability are eliminated * 30 DAY ELIMINATION WITH 24 MONTH CRITICAL PERIOD – Same as above * 12 MONTH CRITICAL PERIOD – Same as above except there are only 12 benefit periods; loan must mature for at least 3 years before insurance can be used * 36 MONTH CRITICAL PERIOD – Same as above except there are 36 benefit periods; loan must mature for at least 5 years before insurance can be used
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