LOAN FORM

  1. Borrower’s Personal Data

Name………………………………………………………………………………………………………….Date of Birth ……………………………

ID No…………………………………PIN No…………………………………………. Gender…………………………………………………………

Postal Address……………………………….Postal code………………………………Mobile Phone No……………………………………

County…………………………………………Sub County………………………………….……Ward……………………………………………….

Village…………………………………………………..Nearest Trading Centre……………………………………………………………………..

  1. Borrower’s Family Data

Spouse’s Name: ………………………………………………………………. ID No……………………………………………………………………

…………………………………………………………………………………………. ID No……………………………………………………………………

Number of children………………………………………………Children’s Age……./……./……./……./……./……./……./……./…….

Number of Dependents……………………………………Dependent’s Age……./……./……./……./……./……./……./……./…….

  1. Economic Activities

Household Member / Agriculture/ Aquaculture / Years of Experience / Livestock / Years of Experience
Other Economic Activities
Household’s Members / Economic Activities Undertaken / Revenue Received / Frequency
  1. Land ownership

Size in Acres/Hectares / Nature of Ownership / Location Details
  1. Summary of Pieces of Land to be farmed

Land Size in Acres/ Hectares / Farm Locations / Type of Farming to be carried out / Person Responsible
County / Sub County / Village
  1. Borrower’s credit History

Lender / The loan Facilities’ Particulars
Date Borrowed / Amount / Outstanding Balance / Completion Date
  1. Desired Characteristics of Loan Applied for

Amount Applied for ……………………………………………………………Desired Tenure……………………………………………………

Preferred Initial Disbursement Date………………………………… Preferred First Repayment Date…………………………..

Preferred type of Repayment: Biweekly/Monthly/ Bimonthly/Quarterly/Half annually/ Annually/Biannually

Preferred Number of Repayments…………………….Do you want to pay the Loan Interest Monthly?......

  1. References and Management Capacity

Scores as follows: Excellent=3, Good=2, Fair=1 and Poor=0 / Score
Character and Management Capacity
Peer Assessment
Management Capacity
Credit History
Agriculture Risk Management Practices
Total
Reference Person / Postal or Physical Address / Mobile Phone Number
1.
2.
3.
  1. Inventory of Family Machinery, Equipment and Household Equipment and Other Valuables

Qty. / Description / Condition / Remaining Useful Life (yrs.) / Current Sale Value / Estimated Annual Depreciation
Household Furniture, Equipment and Valuables
Sub Total
Current Farm and other Productive Equipment
Sub Total
Plant and/or Buildings
Sub Total
Grand Total
  1. Pre- Loan Balance Sheet

Assets / Amount / Liabilities / Amount
Cash at Hand / Account payable/Short term
Cash in the Bank/ Cooperative Society/ Mpesa / Short term Household Liabilities
Stock/Inventory (Agriculture) / Short term Loans
Stock/Inventory (Trade)
Stock/Inventory (Other Economic Activities) / Other Current Liabilities
Account Receivable(Short term) / Lease
Account Receivable(Long term) / Account Payable/Long term
Machinery and Equipment / Long term Loans
Household fixed Assets and Valuables / Total Liabilities
Plant or/ and Building / Equity
Land / Net Income year to date (retained)
Other Assets
Total Assets / Total Liabilities
  1. Collateral and Guarantees Offered

Description of Collateral / Specification / Ownership / Location / Value
Total Collateral Offer
Co- Signature Guarantors
Name / Member Client No. / Current Savings Account Balance / Amount Guaranteed / Guarantor’s Average Monthly Income
1.
2.
3.
Total Guarantees
  1. On and Off Farm Expenditure

a)Expenditure on Farm Inputs

Crop / Type of Input Required / Recommended quantity per acre/Ha / Acres/Ha under cultivation / Price / Time the input is required

b)Expenditure on Livestock

Animal Type / Type of Input Required / Recommended quantity per head / Total Number of Animals / Price / Time the input is required

c)Expenditure on Labor

Crop/ Livestock / Activity / Person days per Acre/Ha./ Head / Price / Time the labor is required

d)Fixed Assets Being financed by the loan

Asset Description / Estimated Useful life / Estimated Annual Depreciation / Quantity / Unit Price / Time when the item will be purchased

e)Other Farming Expenses

Economic Activity / Quantity / Unit Price / Time when required

f)Family Expenditure

Expenditure Type / Estimated Cost / Time when required
Food
Medical Expenses
Education
Clothing
Rent
Water, Electricity & Telephone
Transport cost and fuel
Entertainment & celebrations
Taxes
Debt Payment
Other expenses
Total
  1. Farming and Non-Farming Income

a)Incomes from Agriculture produce sales

Crops to be Sold / Acres/ Ha. Under Cultivation / Expected Yield per Acre/Ha. / Family Consumption / Price per Unit (Kg/Tonne/Bag) / Expected Payment Time

b)Income from Livestock sales

Type /Species / Number of heads/Units / Price per head/Unit / Expected Payment Time

c)Income from sale of livestock products /by- products

Type /Species / Type of Product/ By Product / Units per day / Number of days per month / Price per Unit / Expected Payment Time

d)Income from other Non- Agriculture Economic Activities

Economic Activity/ Source of Income / Frequency / Expected Payment Time

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