APPLICATION FOR BUSINESS LOAN
Individual ______
Full Address ______
______
Name of Applicant Business ______
Tax I.D. No. or SSN ______
Full Street Address of Business ______
Tel. No. (inc. A/C) ______
City______County______State ______Zip ______
Type of Business ______
Date Business Established ______
Number of Employees (Including subsidiaries and affiliates)
At Time of Application ______If Loan is Approved ______
Subsidiaries or Affiliates (Separate for above) ______
Bank of Business Account and Address:
______
______
Use of Proceeds: Loan Requested Loan Request
(Enter Gross Dollar
Amounts Rounded to
the Nearest Hundreds)
______
Land AcquisitionPayoff SBA Loan
______
New Construction/Payoff Bank Loan
Expansion Repair (Non SBA Associated)
______
Acquisition and/or Repair of Other Debt Payment
Machinery and Equipment(Non SBA Associated)
______
Inventory PurchaseAll Other
______
Working Capitol (including Total Loan Requested
Accounts Payable)
______
Acquisition of ExistingTerm of Loan -
Business(Requested Mat.) ___ Yrs.
______
PREVIOUS SBA OR OTHER FEDERAL GOVERNMENT DEBT: If you or any principals or affiliates have 1) ever requested Government Financing or 2) are delinquent on the repayment of any Federal Debt complete the following:
______
Name of Agency ______
Original Amount of Loan $______
Date of Request ______
Approved or Declined: ______
Balance $ ______
Current or Past Due: ______
ASSISTANCE List the name(s) and occupation of anyone who assisted in the preparation of this form, other than applicant.
Name and Occupation ______
Address ______
Total Fees Paid ______
Fees Due ______
Name and Occupation ______
Address ______
Total Fees Paid ______
Fees Due ______
Note: The estimated burden completing this form is 12.0 hours per response. You will not be required to respond to any collection of information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to U.S. Small Business Administration, Chief, AIB, 409 3rd St., S.W., Washington, D.C. 20416 and Desk Office for Small Business Administration, Office of Management and Budget, New Executive Office Building, room 10202 Washington, D.C. 20503.
OMB Approval (3245-0016). PLEASE DO NOT SEND FORMS TO OMB. SUBMIT COMPLETED APPLICATION TO LENDER OF CHOICE
ALL EXHIBITS MUST BE SIGNED AND DATED BY PERSON SIGNING THIS FORM
BUSINESS INDEBTEDNESS: Furnish the following information on all installment debts, contracts, notes, and mortgages payable. Indicate by an asterisk (*) items to be paid by loan proceeds and reason for paying them (present balance should agree with the latest balance sheet submitted).
[You can add Account# 4, Account# 5…. if you have more than three accounts]
Account # 1
To Whom Payable - Acct #:
______
Original Amount:
______
Original Date:
______
Present Balance:
______
Rate of Interest:
______
Maturity Date:
______
Monthly Payment:
______
Security:
______
Current or Past Due:
______
Account # 2
To Whom Payable - Acct #:
______
Original Amount:
______
Original Date:
______
Present Balance:
______
Rate of Interest:
______
Maturity Date:
______
Monthly Payment:
______
Security:
______
Current or Past Due:
______
Account # 3
To Whom Payable - Acct #:
______
Original Amount:
______
Original Date:
______
Present Balance:
______
Rate of Interest:
______
Maturity Date:
______
Monthly Payment:
______
Security:
______
Current or Past Due:
______
MANAGEMENT (Proprietor, partners, officers, directors, all holders of outstanding stock - 100% of ownership must be shown). Use separate sheet if necessary.
Name and Social Security Number ______
Position and Title ______
Complete Address ______
%Owned
______
*Military Service ______
From ______To ______
*Sex ____ (M or F)
Race*: American Indian/Alaska Native ___ Black/African-Amer. ___ Asian ___
Native Hawaiian/Pacific Islander ___ White ___
Ethnicity* ___ Hisp./Latino ___ Not Hisp./Latino ___
Name and Social Security Number ______
Position and Title ______
Complete Address ______
% Owned
______
*Military Service ______
From ______To ______
*Sex ____ (M or F)
Race*: American Indian/Alaska Native ___ Black/African-Amer. ___ Asian ___
Native Hawaiian/Pacific Islander ___ White ___
Ethnicity* ___ Hisp./Latino ___ Not Hisp./Latino ___
*This data is collected for statistical purpose only. It has no bearing on the credit decision to approve or decline this application. One or more boxes may be selected.
THE FOLLOWING EXHIBITS MUST BE COMPLETED WHERE APPLICABLE. ALL QUESTIONS ANSWERED ARE MADE A PART OF THE APPLICATION.
For Guarantee Loans please provide an original and one copy (Photocopy is Acceptable) of the Application Form, and all Exhibits to the participating lender. For Direct Loans submit one original copy of the application and Exhibits to SBA.
1. Submit SBA Form 912 (Statement of Personal History) for each type of individual that the Form 912 requires.
2. If your collateral consists of (A) Land and Building, (B) Machinery and Equipment, (C) Furniture and Fixtures, (D) Accounts Receivable, (E) Inventory, (F) Other, please provide an itemized list (labeled Exhibit A) that contains serial and identification numbers for all articles that had an Original value of greater than $500. Include a legal description of Real Estate Offered as collateral.
3. Furnish a signed current personal balance sheet (SBA Form 413 may be used for this purpose) for each stockholder (with 20% or greater ownership), partner, officer, and owner. Include the assets and liabilities of the spouse and any close relatives living in the household. Also, include your Social Security Number. The date should be the same as the most recent business financial statement. Label it Exhibit B.
4. Include the financial statements listed below: a,b,c for the last three years; also a,b,c, and d as of the same date, - current within 90 days of filing the application; and statement e, if applicable. Label it Exhibit C (Contact SBA at < for referral if assistance with preparation is wanted.) All information must be signed and dated.
a. Balance Sheet
b. Profit and Loss Statement (if not available, explain why and substitute Federal income tax forms)
c. Reconciliation of Net Worth
d. Aging of Accounts Receivable and Payable (summary not
detailed)
e.Projection of earnings for at least one year where financial statements for the last three years are unavailable or when SBA requests them.
5. Provide a brief history of your company and a paragraph describing the expected benefits it will receive from the loan. Label it Exhibit D.
6. Provide a brief description similar to a resume of the education, technical and business background for all the people listed under Management. Label it Exhibit E.
ALL EXHIBITS MUST BE SIGNED AND DATED BY PERSON SIGNING THIS FORM
7. Submit the names, addresses, tax I.D. number (EIN or SSN), and current personal balance sheet(s) of any co-signers and/or guarantors for the loan who are not otherwise affiliated with the business as Exhibit F.
8.Include a list of any machinery or equipment or other non-real estate assets to be purchased with loan proceeds and the cost of each item as quoted by the seller as Exhibit G. Include the seller's name and address.
9. Have you or any officers of your company ever been involved in bankruptcy or insolvency proceedings? If so, please provide the details as Exhibit H. If none, check here: Yes _____ No _____
10. Are you or your business involved in any pending lawsuits? If yes, provide the details as Exhibit I. If none, check here: Yes _____ No _____
11. Do you or your spouse or any member of your household, or anyone who owns, manages or directs your business or their spouses or members of their households work for the Small Business Administration, Small Business Advisory Council, SCORE or ACE, any Federal Agency, or the participating lender? If so, please provide the name and address of the person and the office where employed. Label this Exhibit J. If none, check here: _____
12. Does your business, its owners or majority stockholders own or have a controlling interest in other businesses? If yes, please provide their names and the relationship with your company along with a current balance sheet and operating statement for each. This should be Exhibit K.
13. Do you buy from, sell to, or use the services of any concern in which someone in your company has a significant financial interest? If yes, provide details on a separate sheet of paper labeled Exhibit L.
14.If your business is a franchise, include a copy of the franchise agreement and a copy of the FTC disclosure statement supplied to you by the Franchisor. Please include it as Exhibit M.
CONSTRUCTION LOANS ONLY
15.Include as a separate exhibit (Exhibit N) the estimated cost of the project and a statement of the source of any additional funds.
16. Provide copies of preliminary construction plans and specifications. Include them as Exhibit O. Final plans will be required prior to disbursement.
EXPORT LOANS
17. Does your business presently engage in Export Trade? Yes _____ No _____
18. Will you be using proceeds from this loan to support your company's exports?
Yes _____No _____
19. Would you like information on Exporting? Yes _____ No _____
AGREEMENTS AND CERTIFICATIONS
Agreements of non-employment of SBA Personnel: I agree that if SBA approves this loan application I will not, for at least two years, hire as an employee or consultant anyone that was employed by SBA during the one year period prior to the disbursement of the loan.
Certification: I certify: (a) I have not paid anyone connected with the Federal Government for help in getting this loan. I also agree to report to the SBA office of the Inspector General, Washington, DC 20416 any Federal Government employee who offers, in return for any type of compensation, to help get this loan approved.
(b) All information in this application and the Exhibits are true and complete to the best of my knowledge and are submitted to SBA so SBA can decide whether to grant a loan or participate with a lending institution in a loan to me. I agree to pay for or reimburse SBA for the cost of any surveys, title or mortgage examinations, appraisals, credit reports, etc., performed by non-SBA personnel provided I have given my consent.
(c) I understand that I need not pay anybody to deal with SBA. I have read and understand SBA Form 159, which explains SBA policy on representatives and their fees.
(d) As consideration for any Management, Technical, and Business Development Assistance that may be provided, I waive all claims against SBA and its consultants.
If you knowingly make a false statement or overvalue a security to obtain a guaranteed loan from SBA, you can be fined up to $10,000 and/or imprisoned for not more than five years under 18 USC 1001; if submitted to a Federally insured institution, under 18 USC 1014 by Imprisonment of not more than twenty years and/or a fine of not more than $1,000,000. I authorize the SBA's Office of Inspector General to request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for programs authorized by the Small Business Act, as amended.
If Applicant is a proprietor or general partner, sign below:
By
______
If Applicant is a Corporation, sign below:
______
Corporate Name and Seal Date
By
______
Signature of President
Attested by ______
Signature of Corporate Secretary
SUBMIT COMPLETED APPLICATION TO LENDER OF CHOICE
APPLICANT'S CERTIFICATION
By my signature, I certify that I have read and received a copy of the "STATEMENTS REQUIRED BY LAW AND EXECUTIVE ORDER" which was attached to this application. My signature represents my agreement to comply with the approval of my loan request and to comply, whenever applicable, with the hazard insurance, lead-based paint, civil rights or other limitations in this notice.
Each proprietor, each General Partner, each Limited Partner or Stockholder owning 20% or more, each Guarantor and the spouse of each of these must sign. Each person should sign only once.
Business Name
______
Signature and Title
______
Date
Guarantors
______
Signature and Title ______
Date
Signature and Title ______
Date
Signature and Title ______
Date
Signature and Title ______
Date
Signature and Title ______
Date
Signature and Title ______
Date
Signature and Title ______
Date
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U.S. SMALL BUSINESS ADMINISTRATION
SCHEDULE OF COLLATERAL
Exhibit A
Applicant
______
Street Address
______
City ______State ______Zip Code ______
LIST ALL COLLATERAL TO BE USED AS SECURITY FOR THIS LOAN
Section I -REAL ESTATE
Attach a copy of the deed(s) containing a full legal description of the land and show the location (street address) and city where the deed(s) is/are recorded. Following the address below, give a brief description of the improvements, such as size, type of construction, use, number of stories, and present condition (use additional sheet if more space is required).
LIST PARCELS OF REAL ESTATE
Address
______
Year Acquired
______
Original Cost
______
Market Value
______
Amount of Lien
______
Name of Lienholder
______
Description(s)
______
SUBMIT COMPLETED APPLICATION TO LENDER OF CHOICE
SECTION II - PERSONAL PROPERTY
All items listed herein must show manufacturer or make, model, year, and serial number. Items with no serial number must be clearly identified (use additional sheet if more space is required).
Description - Show Manufacturer, Model, Serial No.
______
______
______
Year Acquired
______
Original Cost
______
Market Value
______
Current Lien Balance
______
Name of Lienholder
______
All information contained herein is TRUE and CORRECT to the best of my knowledge. If you knowingly make a false statement or overvalue a security to obtain a guaranteed loan from SBA, you can be fined up to $10,000 and/or imprisoned for not more than five years under 18 USC 1001; if submitted to a Federally Insured Institution, under 18 USC 1014 by Imprisonment of not more than twenty years and/or a fine of not more than $1,000,000. I authorize the SBA's Office of Inspector General to request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for programs authorized by the Small Business Act, as amended.
Name
______
Date
Name
______
Date
NOTE: The estimated burden for completing this form is 2.25 hours per response. You will not be required to respond to collection of information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to U.S. Small Business Administration, Chief, AIB, 409 3rd St., SW, Washington, D.C. 20416 and Desk Officer for Small Business Administration, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503.
OMB Approval (3245-0016). PLEASE DO NOT SEND FORMS TO OMB.
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SUMBMIT COMPLETED APPLICATIONS TO LENDERS OF CHOICE
U.S. SMALL BUSINESS ADMINISTRATION
LENDER'S APPLICATION FOR GUARANTY OR PARTICIPATION
SBA Loan Number ______
Loan Submitted As:
Reg 7(a) ______
CLP ______
PLP ______
Business Name of Applicant ______
Name of Lender
______
Telephone (Inc. A/C)
______
Street Address
______
City ______State ______Zip ______
R.L. Polk's Lender No. (SBA's Use) ______
WE PROPOSE TO MAKE A (Check One)
Guaranteed Loan ______Lender's Share ______%
SBA's Share ______%
Term of Loan ______Years
Amount of Loan $ ______
Immediate Participation Loan (Lender to make and service)
Lender's Share ______SBA's Share ______%
Payment Beginning ______Months from Date of Note
Monthly Payment $ ______
Lender's Interest Rate ______% Per Annum
If Interest Rate is to be Variable - Base Rate ______
Adjustment Period Spread ______Base Rate Source ______
CONDITIONS OF LENDER (e.g. Insurance requirements, standbys, other conditions. Use additional sheet(s))
______
I approve this application to SBA subject to the terms and conditions outlined above. Without the participation of SBA to the extent applied for we would not be willing to make this loan, and in our opinion the financial assistance applied for is not otherwise available on reasonable terms. I certify that none of the Lender's employees, officers, directors, or substantial stockholders (more than 10%) have a financial interest in the applicant.
Lender Official (Please Type or Print Name under Signature)
______
Title
______
Date
ON PLP SUBMISSIONS ONLY: I approve and certify that the applicant is a small business according to the standards in 13 CFR 121, the loan proceeds will be used for an eligible purpose, and the owners and managers of the applicant business are of good character.
Approving/Certifying Lender Official (Please Type or Print Name under Signature)
______
Title
______
Date
INSTRUCTIONS: Lender will complete and enclose as part of this application package, all working papers, support material, and agreements requested herein, specifically including:
1. Balance sheet and ratio analysis - comments on trends, debt to worth, and current ratio.
2. Lender's analysis of repayment ability.
3.Management skill of the applicant.
4. Collateral offered and lien position, and analysis of collateral adequacy.
5.Lender's credit experience with the applicant. Identify weaknesses.
FINANCIAL SPREAD
In Column 1 please show the most recent balance sheet figures of an existing business or the initial equity investment of a start-up business or the purchase of a business. Columns 2 and 3 are to reflect adjusting entries, the use of loan proceeds, and loan repayment. Column 4 is to reflect the balance sheet of the business immediately following loan disbursement. Base the financial analysis on Column 4 figures.
BALANCE SHEETAs ofFiscal Year EndsAUDITED__AUDITED__
DEBIT CREDITPRO FORMA
Assets
______
Cash
______
Accounts Rec.
______
Inventory
______
Other
______
Total Current Assets
______
Fixed Assets
______
Other Assets
______
Total Assets
______
Liabilities & Net Worth
______
Accounts Payable
______
Notes Payable
______
Taxes
______
Other
______
SBA
______
Total Current Liabilities
______
Notes Payable
______
SBA
______
Other
______
Total Liabilities
______
Net Worth
______
Total Liab. & Net Worth
______
Profit & LossPRIOR THREE YEARSINTERIMPROJECTIONS
Sales
______
Depreciation
______
Income Taxes
______
W/D Officer Comp.
______
Net Profit after Tax/Deprec.
______
PRO FORMA SCHEDULE OF FIXED OBLIGATIONS
YEAR 1YEAR 2 YEAR 3 YEAR 4
$ ______$ ______$ ______$ ______
Lender's Analysis:
______
The estimated burden for completing this form is 12.50 hours per response. You will not be required to respond to collection of information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to U.S. Small Business Administration, Chief, AIB, 409 3rd St., S.W. Washington, D.C. 20416 and Desk Office for Small Business Administration, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 30503. OMB Approval (3245-0016) PLEASE DO NOT SEND FORMS TO OMB.
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U.S. SMALL BUSINESS ADMINISTRATION APPLICATION