Consumer Loan Application

Platte Valley Companies

Consumer Loan Application

Credit Application

Check the appropriate boxes and complete the applicable sections. Use 'NA' for blank fields.








YesNo

SecuredUnsecured

Description of Collateral:
















Section A

Individual Applicant Information




























OwnRent















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.


NACourt OrderWritten AgreementOral Understanding





NoYes



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.


NACourt OrderWritten AgreementOral Understanding





NoYes



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.


MarriedSeparatedUnmarried (including single, divorced or widowed)

NAMarriedSeparatedUnmarried (including single, divorced or widowed)

Section D

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


NoYes





NoYes





NoYes





NoYes




Section E - Insurance

Platte Valley Bank - Nebraska, Wyoming (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 Platte Valley Bank location that you bank at or the location nearest you.


NOTICE - Joint Intent


We intend to apply for joint credit (Signatures Required BelowI 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 Platte Valley Bank extends credit.





To Credit Applicant

Platte Valley Bank advised you we may not condition the extension of credit on the following:

-Your purchase of insurance from Platte Valley or any of its affiliates;


-Your agreement to not obtain insurance from an entity not affiliated with Platte Valley Bank.

In addition, Platte 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

 

 

 

GET THE MORTGAGE LOANS YOU NEED.

GET THE MORTGAGE LOANS YOU NEED.

Find your nearest Platte Valley Bank

Platte Valley Bank is pleased to offer a wide variety of accounts and services to meet the needs and lifestyles of all of our personal banking customers. Whether you need a checking account with no minimum balance requirement, a savings account with a competitive interest rate, or a personal loan to help you achieve your goals, we have a product to meet your needs.

Nebraska Main Bank

Scottsbluff Phone: 308-632-7004 Toll Free: 888-632-7004

Wyoming Main Bank

Torrington Phone: 307-532-2111 Toll Free: 800-777-8999

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Contact

Nebraska Main Bank Scottsbluff Phone: 308-632-7004 Toll Free: 888-632-7004
Wyoming Main Bank Torrington Phone: 307-532-2111 Toll Free: 800-777-8999

Regulatory Notices

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