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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




 Consumer 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 02/18/10. 6778c49a-e830-42e0-956c-7149d10620bd.xls
                                                                                                                    CONSUMER LOAN CREDIT APPLICATION
IMPORTANT APPLICANT INFORMATION: Federal law requires financial institutions to obtain sufficient information to verify your identity. You may be asked several
questions and to provide one or more forms of identification to fulfill this requirement. In some instances we may use outside sources to confirm the information. The
information you provide is protected by our privacy policy and the federal law.
                                            TYPE OF CREDIT REQUESTED                                                                       FOR CREDITOR USE
            IMPORTANT: Check (x) the appropriate box below and complete the applicable sections.                          DATE ____________              CLASS _______
       SECURED           JOINT CREDIT - we intend to apply f or joint credit (initials)                                   ACCOUNT NO. ____________________
       UNSECURED                  INDIVIDUAL CREDIT - rely ing solely on my income or assets
       INDIVIDUAL CREDIT - rely ing on my income or assets as well as income or assets f rom other sources                APPROVED     BY _______________
AMOUNT REQUESTED                       FOR HOW LONG            PAYMENT DATE             WANT TO REPAY                     PROCEEDS OF LOAN TO BE USED FOR:
                                                                                             Monthly
                                                                                             Other (Specify)
                                                           SECTION A – INDIVIDUAL APPLICANT INFORMATION
NAME (Last, First, Middle)


BIRTHDATE         TELEPHONE NO.                   DRIVER’S LICENSE NO.                              SOCIAL SECURITY NO.                       NO. DEPENDENTS/ AGES


ADDRESS (Street, City, State & Zip)                                                                            COUNTY               Do you             own           HOW LONG?
                                                                                                                                      or               rent
ADDRESS (Street, City, State & Zip) (Complete if less than 3 years at present address)                         COUNTY               Do you             own           HOW LONG?
                                                                                                                                      or               rent
EMPLOYER (Company Name & Address)                                                                                                                                    HOW LONG?


BUSINESS PHONE, Ext.           POSITION OR TITLE                                                                                       GROSS INCOME
                                                                                                               Monthly:                             Annual:
PREVIOUS EMPLOYER                                                                                                                                                    HOW LONG?

NAME AND ADDRESS OF NEAREST RELATIVE NOT LIVING WITH YOU                                                                  RELATIONSHIP                         TELEPHONE NO.


Alimony, child support, or separate maintenance income need not be reviewed if you do not wish to have it considered as a basis for repaying this obligation.
     Alimony, child support, separate maintenance received under:                   Court Order           Written Agreement              Oral Understanding
SOURCES OF OTHER INCOME                                                                                                                                  AMOUNT PER MONTH


Is any income listed in this Section likely to be reduced before the credit request is paid off?
      No        Yes

                                                  SECTION B – JOINT APPLICANT OR OTHER PARTY INFORMATION
NAME (Last, First, Middle)


BIRTHDATE         TELEPHONE NO.                   DRIVER’S LICENSE NO.                              SOCIAL SECURITY NO.                       NO. DEPENDENTS/ AGES


ADDRESS (Street, City, State & Zip)                                                                            COUNTY               Do you             own           HOW LONG?
                                                                                                                                      or               rent
ADDRESS (Street, City, State & Zip) (Complete if less than 3 years at present address)                         COUNTY               Do you             own           HOW LONG?
                                                                                                                                      or               rent
EMPLOYER (Company Name & Address)                                                                                                                                    HOW LONG?

BUSINESS PHONE, Ext.           POSITION OR TITLE                                                                                       GROSS INCOME
                                                                                                               Monthly:                        Annual:
PREVIOUS EMPLOYER                                                                                                                                                    HOW LONG?


NAME AND ADDRESS OF NEAREST RELATIVE NOT LIVING WITH YOU                                                                  RELATIONSHIP                         TELEPHONE NO.


Alimony, child support, or separate maintenance income need not be reviewed if you do not wish to have it considered as a basis for repaying this obligation.
     Alimony, child support, separate maintenance received under:                   Court Order           Written Agreement              Oral Understanding
SOURCES OF OTHER INCOME                                                                                                                                  AMOUNT PER MONTH


Is any income listed in this Section likely to be reduced before the credit request is paid off?
      No         Yes

                                                                SECTION C – MARITAL STATUS
 Complete only if: for joint or secured credit, applicant resides in a community property state or is relying on property located in such a state as a basis for
APPLICANT                Married        Separated
                                                                repayment of the credit requested.
                                                           Unmarried (including single, div orced, and widowed)

OTHER PARTY                  Married          Separated            Unmarried (including single, div orced, and widowed)




 Page 1 of 2                                                                                                                                  Please Initial
                                                     SECTION D – ASSET & DEBT INFORMATION
If Section B has been completed, this Section should include information about both the Applicant and Joint Applicant or Other Person.
Please mark Applicant-related information with an “A”. If Section B was not completed, only give information about the applicant in this section.
ASSETS OWNED (Use separate sheet if necessary.)

                         DESCRIPTION OF ASSETS                                  NAME IN WHICH ASSET HELD                    SUBJECT TO DEBT?                      VALUE

CHECKING ACCOUNT (number and institution)


SAVINGS ACCOUNT(number and institution)


CERTIFICATES OF DEPOSIT(s) (institution)


MARKETABLE SECURITIES (issuer, type, no. of shares)


REAL ESTATE (location, date acquired)


LIFE INSURANCE (issuer, face value)


AUTOMOBILES (make, model, year)


OTHER (list)


                                                                                                                              TOTAL ASSETS
OUTSTANDING DEBTS (Including charge accounts, installment contracts, credit cards, rent, mortgages and other obligations. Use separate sheet if necessary.)
                                                                           NAME IN WHICH ACCOUT IS                                                                      MONTHLY
                   CREDITOR                      ACCOUNT NUMBER                                               ORIGINAL AMOUNT             PRESENT BALANCE
                                                                                   CARRIED                                                                              PAYMENT
                                                            Rent
   LANDLORD OR MORTGAGE HOLDER
                                                            Mortgage
           AUTOMOBILES (describe)



            OTHER DEBT (describe)




                                                                                             TOTAL DEBTS

                        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?                  No        Yes
     If yes, to (Name & Address)                                                                                                             Amount per Mo.?
Are you a co-maker, endorser, or guarantor on any loan or contract?           No          Yes (to whom?)
Are there any unsatisfied judgments against you?          No        Yes (to whom?)

Have you been declared bankrupt in the last 10 years?          No      Yes (where?)                                                                            Year?
                                                                   SECTION E – SECURED CREDIT
                                    Complete only if credit is to be secured. Briefly describe the property to be given as security.
PROPERTY DESCRIPTION


NAMES & ADDRESSES OF ALL CO-OWNERS OF THE PROPERTY


IF THE SECURITY IS REAL ESTATE, GIVE THE FULL NAME OF YOUR SPOUSE (if any)


BLANKET AUTHORIZATION I certify that everything state in this application and on any attachments is true and correct. I have made no misrepresentations in this application or
with other documents, nor did I omit any pertinent information. I fully understand that it is a Federal crime to knowingly make any false statements when applying for a loan. The
Lender may keep this application whether or not it is approved. I hereby give 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, it’s agents, successors, and assigns either directly or through a credit reporting agency. I understand that I must update credit information 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
                                                                         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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