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					                                                                    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. b9b4c01b-b06d-42a7-acc4-68d4e577f0ea.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                         LOT DATA VALUE:                        Original Cost                  Present Value (a)                Cost of Improvements (b)                  Total
  Construction-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
                                Previous Employer                       City/State                     Type of Business         Position/Title                Dates From/To                 Monthly Income
C - 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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