125Th Street Pilot Retail Incentive Programapplication

125th Street Pilot Retail Incentive ProgramApplication

The application and all supplemental materials should be mailed or delivered to the Upper Manhattan Empowerment Zone, 290 Lenox Avenue, 3rd Floor, New York, NY 10027, Attn: SVP of Business Investments. Please retain a copy of this form and all other materials submitted in support of your application for your records.
Requestand Eligibility Summary
Amount Requested: $ ______(Max. $50,000) / Have you ever borrowed funds from UMEZ or BRISC? Yes No
What is the square footage of retail space at your current/proposed location? ______sq. ft. / How much you pay annually for rent? $______/ When does your current lease expire? _____/_____/_____
Purpose of funding? / Start-up Funding Working Capital Other: ______
Business Expansion Business Relocation ______
Business Information
Business Name (Exact Legal Name) / Business Contact Name
Business Street Address (P.O. Box not acceptable) / Business Phone Number
( ) / Business Fax Number
( )
City / State / Zip Code / EIN #
Project Name (if different from Business Name) / Applicant certifies business is organized under the laws of the State of ______
Sole-Proprietorship Partnership LLC
“S” Corporation “C” Corporation Other / Website/E-mail address:
Type of Business: Retailer Service
Established when?
____/____/____ / Business Description / # Employees / Annual Revenue
$
If you answer “Yes” to any of the following, please explain by attaching a separate sheet.
Has management or the business ever declared bankruptcy?
Yes No / Is the business a guarantor for debt?
Yes No
Does the business owe any taxes (e.g., income, sales,withholding, etc.)? Yes No / Are any business assets pledged or assigned?
Yes No
Ownership/Management (Anyone with 10% or more interest in the Company)
Name / Social Security Number / Address / % Owned
Business Financial Obligations
Lender / Approved Amount / Outstanding / Maturity Date / Monthly Payment
References - Please listtwo (2) professional references (one of which must be your landlord)
Name / Relationship / Address / Telephone
Current Landlord / Primary: ( )
Secondary: ( )
Primary: ( )
Secondary: ( )
Signature(s)
I/we understand that the information on this application was given to UMEZ for the purpose of obtaining funding and I/we certify that the above information is true and accurateas of the date below. I/we understand that any false or misleading information will be an immediate cause for declining the application. I/we agree to promptly notify UMEZ of any changes to the above information and we authorize UMEZ to obtain credit reports on the principal(s). I/we understand that UMEZ reserves the right to request additional information if needed. I/we understand that the receipt of this application does not obligate UMEZ to approve funding.
______
Name (Print) Signature Date
______
Name (Print) Signature Date
______
Name (Print) Signature Date

May 2008