www.banksanjuans.com
One big happy little bank.
CREDIT APPLICATION / PERSONAL FINANCIAL STATEMENT
Please read these directions before completing this Statement, and check the appropriate box below
If you are applying for individual credit in your own name and relying on your own income or assets and not the income or assets of another person,
complete Parts 1 and 3.
If you are applying for joint credit with another person, complete all Parts providing information in Part 2 about the joint application.
If you are applying for individual credit, but are 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 credit requested, complete all sections, providing information in Part 2 about the person whose alimony,
support,or maintenance payments or income or assets you are relying.
If this statement relates to your guaranty of the indebtedness of other person(s), firm(s) or corporation(s), complete Parts 1 and 3.
AMOUNT REQUESTED
FOR HOW LONG
PAYMENT DATE DESIRED
WANT TO REPAY
Monthly
INDIVIDUAL APPLICANT INFORMATION
Email
P
A
R
T
O
N
E
Name
Home Phone
S .S.#
Address (Physical)
City/State/Zip
Address (Mailing)
City/State/Zip
Time at this Address
PROCEEDS OF LOAN TO BE USED FOR
Other
Number of Dependents/Ages
Date of Birth
Driver’s Lic#
Previous Address
State
Time at this Address
Employer Name
Position or Occupation
Employer Address
Length of employment
City/State/Zip
Previous Employer
Length of employment
Business Phone
Primary Insurance Provider
Name/ Address/Phone of Nearest Relative (Not Living with You)
JOINT APPLICANT OR OTHER PARTY INFORMATION
Email
P
A
R
T
T
W
O
Name
Home Phone
S .S.#
Address (Physical)
City/State/Zip
Address (Mailing)
City/State/Zip
Time at this Address
Number of Dependents/Ages
Date of Bir th
Driver’s Lic#
Previous Address
State
Time at this Address
Employer Name
Position or Occupation
Employer Address
Length of employment
City/State/Zip
Previous Employer
Length of employment
Business Phone
Primary Insurance Provider
Name/ Address/Phone of Nearest Relative (Not Living with You)
ASSETS
LIABILITIES AND NET WORTH
CURRENT ASSETS
VALUE
Cash in Accounts/Held Where?
P
A
R
T
T
H
R
E
E
CURRENT LIABILITIES
Mortgages on Real Estate or Rent
(Complete Schedule 3)
$
Cash in Accounts/Held Where?
Life Insurance-Cash Surrender Value Only
(Complete Schedule 5)
Stocks/Bonds/Mutual Funds
(Complete Schedule 2)
Accounts and notes receivable
(Complete Schedule 4)
Accounts Payable
Other Current Assets (Please List)
Other Revolving Debt (Please List Below)
MONTHLY
PAYMENT
$
BALANCE
$
Revolving Credit (i.e. Credit Cards)
Revolving Credit (i.e. Credit Cards)
Revolving Credit (i.e. Credit Cards)
(a) TOTAL CURRENT ASSETS
$
0.00
TOTAL CURRENT LIABILITIES
$
0.00
$
0.00
Installment Notes (to banks & others)
FIXED ASSETS
IRA or Other Retirement Account
Real Estate (Complete Schedule 3)
Automobile Make
Year
Automobile Make
Year
Other Personal Property
Other Debt (Please List)
Net Worth of Business(es) owned/Attach Schedule
Notes Receivable Long Term (Complete Schedule 4)
Other Fixed Assets (Please List)
Unpaid Taxes
(c)
(b)
TOTAL FIXED ASSETS
(a + b)
TOTAL ASSETS
TOTAL LIABILITIES
$
0.00
(a + b) - (c) NET WORTH
$
0.00
$
0.00
TOTAL LIABILITY AND NET WORTH
$
0.00
(Please complete the information on the reverse side of this form as outlined above and sign)
SCHEDULE 1
SOURCE OF INCOME
Gross Monthly Income
Applicant
Other Party
Total
$
$
Salary
0.00
0.00
0.00
0.00
0.00
$
Net Investment Income
Real Estate Income
Other Income *(Describe Below)
Total
0.00
$
0.00
$
$
Description of Other Income
Is any income listed in this section likely to be reduced before the credit request is paid off?
* Alimony, child support, or separate maintenance payments need not be disclosed in “Other Income” unless you wish to have such payments considered as a
basis for repaying this obligation.
SCHEDULE 2
STOCKS/BONDS/MUTUAL FUNDS
Number of Shares
Name of Security
SCHEDULE 3
Market Value
Exchange (i.e. Amex)
Pledged?
REAL ESTATE OWNED
Property A
Property B
Property C
Property D
Property Address
Name of Title Holder
Date Purchased
Original Cost
Present Market Value
Name of Mortgage Holder
% of Ownership
Mortgage Balance
Amount of Payment
per month/year
Amount of Rental Income
SCHEDULE 4
Original Date
NOTES RECEIVABLE
Original Amount
SCHEDULE 5
Amount
Due From
Balance Owing
Payments
Maturity
Collateral
LIFE INSURANCE
Name of Company
APPLICANT/JOINT APPLICANT QUESTIONS
Cash Value
Loans
Applicant
Joint Applicant
Do you have any combined contingent expenses as an Endorser, Co-Maker?
Yes / No
Yes / No
If so, how much?
Any Legal Claims or adjustments?
Yes / No
Yes / No
If so, how much?
Any provision of federal income tax?
Yes / No
Yes / No
If so, how much?
Any other special debt?
Yes / No
Yes / No
If so, how much?
Are you a U.S. Citizen?
Yes / No
Yes / No
Are you a defendant in any suits or legal actions?
Yes / No
Yes / No
If so, explain.
Have you declared bankruptcy in the last 10 years?
Yes / No
Yes / No
If so, what year?
Are you obligated to make alimony, support, or maintenance payments?
Yes / No
Yes / No
If so, explain.
Beneficiary
Everything that I have stated in this application is correct to the best of my knowledge. I understand that the Bank will retain this application whether or not it is approved. The
Bank is authorized to check my credit and employment history and to answer questions about the Bank’s credit experience with me. I understand that I must update my credit
information at the Bank’s request if my financial condition changes. By signing I also acknowledge receipt of a copy of the Bank’s Privacy Promise.
Applicant’s Signature
Date
Signature (Joint/Other Party)
144 East Eighth Street Durango, CO 81301 ph: (970) 247-1818 fax: (970) 247-1150
1710 Main Ave., Durango, CO 81301 ph: ( 970) 247-2828 fax: (970) 375-1414
P.O. Box 2830 305 Hot Springs Blvd. Pagosa Springs, CO 81147 ph: (970) 264-1818 fax: (970) 264-0066
Date
LOAN REQUEST
Please provide a copy of your photo ID
One big happy little bank.
Date: ____________________
The purpose of the loan is ________________________________________________________________________________
I am applying for individual credit in my own name and I am relying on my own income and
assets and not the income or assets of another person.
I am applying for individual credit and I am relying on my income or assets, as well as income or assets from
other sources.
We are applying for joint credit.
JOINT APPLICANT OR OTHER PARTY INFORMATION
U.S. Citizen
Resident Alien
Non-Resident Alien
Printed Name
Signature
Country of Citizenship
Mother’s Maiden Name
JOINT APPLICANT OR OTHER PARTY INFORMATION
U.S. Citizen
Resident Alien
Non-Resident Alien
Printed Name
Signature
Country of Citizenship
Mother’s Maiden Name
JOINT APPLICANT OR OTHER PARTY INFORMATION
U.S. Citizen
Resident Alien
Non-Resident Alien
Printed Name
Signature
Country of Citizenship
Mother’s Maiden Name
••••••••••••••••••••••••••••••••••••••••••••••
Request Taken:
Phone
For Bank Use Only
Written
••••••••••••••••••••••••••••••••••••••••••••••
In Person
Received By:
Bank of the San Juans
Date
144 East 8th Street, Durango, CO 81301 • Phone (970) 247-1818 • Fax (970) 382-8085
1710 Main Ave., Durango, CO 81301 • Phone (970) 247-2828 • Fax (970) 375-1414
305 Hot Springs Blvd., Pagosa Springs, CO 81147 • Phone (970) 264-1818 • Fax (970) 264-0066
Member FDIC
www.banksanjuans.com
Equal Housing Lender
Bank of the San Juans Privacy Promise for Consumers
While information is the cornerstone of our ability to provide superior service, our
most important asset is our customers’ trust. Keeping customer information
secure and using it only as our customers would want us to is a top priority for all
of us at Bank of the San Juans.
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At Bank of the San Juans, the basis of each customer relationship is
trust. You have chosen to do business with Bank of the San Juans, and
we are obligated to honor that relationship with great care, beginning with
the information you have chosen to share with us. We believe that your
privacy should not be compromised. At the same time, we want to offer
you the array of products and services you need to accomplish your
financial goals. We believe we can do both through the privacy policy
outlined herein.
We recognize your right to privacy at Bank of the San Juans, we
recognize that you have a right to expect your personal financial
information to remain private and secure. We will maintain standards to
ensure that your information is private and secure at all times, even after
you are no longer a customer of our bank.
Information about consumers is accumulated from a variety of sources.
Some information is provided to Bank of the San Juans directly by
customers themselves. Other data is developed by Bank of the San Juans
as a function of providing a product or service to a customer. Still other
information is obtained from outside sources. We will limit the use and
collection of information about our customers to that which is necessary to
administer our business, provide superior service and offer opportunities
that we think will be of interest to customers. This means that we will use
the information to help us identify and mitigate potential risks and loss to
Bank of the San Juans. We will use information to help identify additional
products or services, which we believe customers might want to know
about. We will use this information only in accordance with the principles
set out in this Policy.
We continually strive to maintain complete and accurate information
about you and your accounts. Should you ever believe that our records
contain inaccurate or incomplete information about you, please notify us.
We will investigate your concern and correct any inaccuracies.
Each Bank of the San Juans employee is required to follow our
Company’s “Standards of Conduct,” which states that all customer
information is considered private and privileged and is to be used solely
for the purpose of providing you with the finest service available.
We safeguard information according to established standards and
procedures, and we continually assess new technology for protecting
information. Our employees are trained to understand and comply with
these information principles.
It is the bank’s policy not to reveal specific information about customer
accounts or other personally identifiable data to unaffiliated third parties
for their independent use, except for the exchange of information with
reputable information reporting agencies to maximize the accuracy and
security of such information or in performance of bona fide corporate due
diligence or business matter, unless 1) the information is provided to help
complete a customer initiated transaction; 2) the customer requests or
permits it; 3) the information is required by or allowed by law (e.g.,
subpoena, investigation of fraudulent activity, request by regulator, etc.) or
4) the customer has been informed about the possibility of disclosure for
marketing or similar purposes through a prior communication and given
the opportunity to decline (i.e., “opt out”).
8. When the bank conducts business with third parties, it requires its
vendors and suppliers to maintain similar standards of conducts regarding
the privacy of personally identifiable customer information provided to
them.
9. At Bank of the San Juans, we value our customer relationship. We want
you to understand how we use the information you provide and our
commitment to ensuring your personal privacy. If you have any questions
about how Bank of the San Juans protects your confidential information,
please call your local branch.
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