Piscataquis County Economic Development Council

PCEDC Small Business Revolving Loan Fund

Application

InstructionsForApplicationForm

SectionsI,II,III.Pleaseprovidetheinformationrequested."You"referstotheproprietor,generalpartner,orcorporateofficersigningthisform.

I.Applicant. InformationaboutYou

Name
StreetAddress
City,State,Zip
Telephone
SocialSecurity#
DateOfBirth

II.InformationaboutYourBusiness

NameofBusiness
AddressofBusiness
City,State,Zip
County
Telephone
E-MailAddress
TypeofBusiness
DateEstablished
PresentNumberofEmployees / NumberofEmployeesAfterApproval
DUNSNumber(RequiredforIRPloans)
IRSEmployerI.D.Number
BankWhereYourBusinessHasanAccount

III.InformationaboutManagement

Listthenameofallowners,officers,directors,and/orpartners. Providepercentofownershipandtheannualcompensation.PleaseprovideSocialSecuritynumbersforanyoneowning20%ormore.

NameandTitle / %ofOwnership
Address / AnnualCompensation
NameandTitle / %ofOwnership
Address / AnnualCompensation
NameandTitle / %ofOwnership
Address / AnnualCompensation
NameandTitle / %ofOwnership
Address / AnnualCompensation

Section IV.Useofthemoney;ifyouruseoftheloanfitsoneofthecategorieslistedontheapplicationform,pleasefilloutthissection.Ifyouuse“other”submit alistonaseparatesheetofpaperandlabelthelistExhibitA.

IV.ProjectUseOfFunds(Includeallsourcesoffunds)

Building / New / Purchase / Renovate
AmountforBuilding / $
AmountforLand / $
AmountforNewEquipment / $
AmountforNotesPayable / $
AmountforWorkingCapital / $
AmountforEquipmentRepair / $
AmountforAccountsPayable / $
Other(SeeInstructions) / $

SOURCESOFFUNDS

1.Borrower / $
2 / $
3 / $
4 / $
5.SCEC / $
TOTALLOANREQUESTED / $
TERMFORSCECLOAN / YEARS / MONTHS

Section V.SummaryofCollateral:Ifyourcollateralconsistsof(A)LandandBuilding,(B)Inventory,and/or(C)Accountsreceivable,fillintheappropriateblanksandprovideacopyofyourrealestatedeedand/oranagingofaccountsreceivable.Ifyouareusing(D)MachineryandEquipment,(E)FurnitureandFixtures,and/or(F)other,pleaseprovideanitemizedlist(labeledExhibitB)thatcontainsserialandidentificationnumbersforallarticlesthathadanoriginalvaluegreaterthan$500.Pleaseprovidecopiesofallapplicableinsurancecoverageoncollateralbeingoffered.

V.SummaryofCollateral

PresentMarketValue / PresentMortgageBalance / DatePurchased / CostWhenPurchased
A.LandandBuildings
B.Inventory
C.AccountsReceivable
D.MachineryandEquipment
E.FurnitureandFixtures
F.Other
Total / $ / - / $- / $ / -

Piscataquis County Economic Development Council (PCEDC), 50 Mayo Street, Dover-Foxcroft, Maine 04426

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Agreements andCertifications

AgreementofNonemploymentofBusinessFinancePersonnel:

I/WeagreethatifPCEDCapprovesthisloanapplicationI/Wewillnot,foratleasttwoyears,hireasanemployeeorconsultantanyonethatwasemployedbythePCEDCduringtheoneyearperiodtothedisbursementoftheloan.

Certification:

I/WecertifythatallinformationinthisapplicationandtheExhibitsaretrueandcompletetothebestofmy/ourknowledgeandissubmittedtoPCEDCsoPCEDCcandecidewhethertograntaloanorparticipatewithalendinginstitutioninaloantome/us.

I/Wegivetheassurancethatwewillcomplywithsections112and113ofvolume13oftheCodeofFederalRegulations.TheseCodesectionsprohibitdiscriminationonthegroundsofrace,color,sex,religion,maritalstatus,handicap,age,ornationaloriginbyrecipientsofFederalfinancialassistanceandrequireappropriatereportsandaccesstobooksandrecords.Theserequirementsareapplicabletoanyonewho buysortakescontrolofthebusiness.I/WerealizethatifI/Wedonotcomplywiththesenon-discriminationrequirementsPCEDCcan,call,terminate,oracceleraterepaymentonmy/ourloan.

AuthoritytoCollectPersonalInformation:

ThisinformationisprovidedpursuanttoPublicLaw93-579(PrivacyActof1974).

EffectonNondisclosure:

Omissionofanitemmeansyourapplicationmightnotreceivefullconsideration.

I/Weauthorizedisclosureofallinformationsubmittedinconnectionwiththisapplicationtothefinancialinstitutionagreeingtoparticipateintheloan.

AsconsiderationforanyManagementandTechnicalAssistancethatmaybeprovided,I/WewaiveallclaimsagainstSCECanditsconsultants.

Advertising:

ItisagreedtobytheapplicantthatthePiscataquisCountyEconomicDevelopment Council(administratorforthisRevolvingLoanFund)mayadvertisethefactthat,ifthisloanisapproved,assistancehasbeenprovidedandthebenefitassociatedtherewith.ALSO:applicantagreestoallowthepostingofasignindicatingthatthePCEDC throughitsRevolvingLoanFundprogramhasprovidedfinancialassistancetoyourbusiness.ALSO;theapplicantagreesthatthePCEDCwillparticipateinallnewsreleasesorcanorganizethesameforanycompletionofthepurposeforwhichtheloanproceedsareused.

AmericanswithDisabilitiesCompliance

BorrowercertifiesthatifloanfundsareforconstructionpurposestheBorrowerissubjecttoandcompliantwiththeAmericanswithDisabilitiesAct,TitleIIIof1990.PleasecontactPCEDCwiththeparticularsoftheAct.

OtherDisclosures

Borrowerunderstandsthattheacceptanceofthisapplicationdoesnotconstituteapprovalorthepursuitofapprovalfortheloanrequested.BorrowerfurtherstatesthatBorrowerunderstandsthisapplicationmaybesubmittedwhencompletetotheRDofficeinBangor.RDmustconcurthattheapplicationmeetsthecriteriaoftheIRPloanfundprogramandnotuntilthisapplicationisentertainedbythelocalloanreviewandexecutivecommitteesandapprovedwillitbesubmittedtoRDforconsideration.BorrowerfurtheracknowledgesthatBorrowerhasreviewedprogramoutlineasdeliveredtothempriortocompletionofthisapplicationandunderstandstheconditionsandlimitationscontainedinthoseoutlinesinapplyingforthisloan.

CertificationConcerningChildSupportObligations

I/WecertifythatI/Wearenotmorethan(60)daysdelinquentunderanyadministrativeorder,courtorder,orotherformalagreementrequiringthepaymentofchildsupport.

ThisinformationisprovidedpursuanttoPublicLaw103-403,Section612.

ApplicationDisclosureStatement

I/Weunderstandthatbysigningthisdisclosurestatementandiftheloanrequestisapproved,I/WewillberesponsibleforallcostsincurredinconnectionwiththeloanthatI/Wehaveappliedfor.IftheloanisapprovedI/wewillberequiredtoprovideadeposituponsigningthecommitmentletterthatisdeemedsufficienttocoverallcostsincurredinprocessingtheloantoclosing.Dependingonthesizeoftheloanthe1%originationfeemaynotbesufficienttocoversaidcostandthedeposit maybelargerthanthe1%fee.

ItisfurtherunderstoodthatiftheloanisapprovedthatI/Wewillberequiredtohavelifeinsuranceinanamountsufficienttocovertheloanandwillberequiredoneachoftheborrowersorontheprincipalsoftheborrower,ifacompany,thatowns20%ormoreofthebusiness.ItisalsounderstoodthatifRealEstateisinvolvedandtakenascollateralTitleinsurancewillberequiredandasurveyofthepropertymayberequiredsothatthesurveyexceptioncanberemovedfromthetitleinsurancepolicy.

Itisalsounderstoodthatthesecostsmayinclude,but maynotbelimitedtoallattorneyandlegalfees, Insurancepremiums,recordingfees,filingfees,terminationanddischargefeesassociatedwiththemakingandclosingofthisloan.

EqualOpportunityandNondisclosureRequirements

InaccordancewithTitleVofP.L.93-495,theEqualCreditOpportunityAct,PCEDC,willnotdiscriminateagainstanyapplicantonthebasisofrace,color,religion,nationalorigin,age,physicalormentalhandicap(providedthattheapplicanthasthecapacitytoenterintoabindingcontract),sexormaritalstatuswithrespecttoanyaspectofacredittransaction.

ThisisanEqualOpportunityProgram.DiscriminationisprohibitedbyFederalLaw.ComplaintsofdiscriminationmaybefiledwiththeUSDA,Director,OfficeofCivilRights,Washington,D.C.20250.

PrivacyActNotice:Thisinformationistobeusedbytheagencycollectingitoritsassigneesindeterminingwhetheryouqualifyasaprospectiveborrowerunderitsprogram.Itwillnotbedisclosedoutsidetheagencyexceptasrequiredandpermittedbylaw.Youdonothavetoprovidethisinformation,butifyoudonotyourapplicationforapprovalasaprospectiveborrowermaybedelayedorrejected.TheinformationrequestedinthisformisauthorizedbyTitle38,USC.Chapter37(ifVA);by12USC.Section1701etseq.(ifHUD/FHA).

Checklist For Application Package

ALLEXHIBITSMUSTBESIGNEDANDDATEDBYTHEPERSONSIGNINGTHISFORM

YES / NO
1.HaveyoufilledoutapersonalfinancialstatementandprovidedcopiesofthelastthreeyearsFederalIncomeTaxReturnsforeachstockholder,partner,officer,andowner(allwith20%orgreaterownership)?LabelthisEXHIBITC.
2.Haveyou includedthestatementslisted below:A, B,Cforthelast threeyears:A,B,C,Ddated within90daysoffilingtheapplication;andstatementE?ThisisEXHIBITD.
A.BalanceSheet
B.ProfitandLossStatement
C.ReconciliationandNetWorth
D.AgingofAccountsReceivableandPayable
E.EarningsProjectionForthree years
F.LastthreeyearscompleteFederalIncomeTaxForms.
3.Haveyoucompletedalistwhichcontainstheoriginaldateandamount,presentbalanceowed,interestrate,monthlypayment,andmaturityandsecurityforeachloanordebtthatyourbusinesscurrentlyhas?Pleaseindicatewhethertheloaniscurrentordelinquent.ThisshouldbelabeledEXHIBITE.(Sampleformattached)
4.HaveyouprovidedaBusinessPlaninaformsatisfactorytoPCEDC?(Samplesareavailable.)LabelthisEXHIBITF.
5.Haveyouprovidedabriefdescriptionoftheeducational,technical,andbusinessbackgroundforallthepeoplelistedundermanagement?Ifnot,youmustdoso.LabelthisEXHIBITH.
6.Doyouhaveanyco-signersand/orguarantorsforthisloan?Ifso,pleasesubmittheirnames,addresses,andpersonalbalancesheetsandlast3yearscompleteFederalIncomeTaxReturnsasEXHIBITH.
7.Areyoubuyingmachineryorequipmentwithyourloanmoney?Ifso,youmustincludealistoftheequipmentandthecost.ThisisEXHIBITJ.
8.Haveyouoranyofficersorguarantorsofyourcompanyeverbeeninvolvedinbankruptcyorinsolvencyproceedings?Ifso,pleaseprovidethedetailsasEXHIBITK.
9.Areyouoryourbusinessinvolvedinanypendinglawsuits?Ifso,pleaseprovidedetailsasEXHIBITL.
10.Doesyourbusinesshaveanysubsidiariesoraffiliates?Ifyes,pleaseprovidetheirnamesandtherelationshipwithyourbusinessalongwithacurrentbalancesheetandoperatingstatementforeachandlastthreeyearscompleteFederalIncomeTaxReturns.ThisshouldbeEXHIBITM.
11.Doyoubuyfrom,sellto,orusetheservicesofanyconcerninwhichsomeoneinyourbusinesshasasignificantfinancialinterest?Ifyes,providedetailsonaseparatesheetofpaperlabeledEXHIBITN.
12.Ifyourbusinessisafranchise,haveyouincludedacopyofthefranchiseagreement?PleaseincludeitasEXHIBITP.
13.Doyouoryourspouseoranymemberofyourhousehold,oranyonewhoowns,manages,ordirectsyourbusinessortheirspousesormembersoftheirhouseholdsworkforPCEDC, NMDC, USDAoranyotherFederalorStateagency?
14.Astatementdemonstratingwhyyouareunabletoobtainthiscreditelsewhereatcomparableratesandtermsandwhyyou feelthebusinesshasagoodprospectforrepayment.
15. Is this loan to be used in combination with grant funds? If yes, please explain.

Racial/EthnicDisclosure

ThefollowinginformationisrequestedbytheFederalGovernmentforcertaintypesofloans,inordertomonitorthelender’scompliancewithequalcreditopportunity.Youarenotrequiredtofurnishthisinformation,butareencouragedtodoso.Thelawrequiresthatalendermayneitherdiscriminateonthebasisofthisinformationnoronwhetheryouchoosetofurnishit.However,ifyouchoosenottofurnishit,underFederalregulations,thislenderisrequiredtonoterace/ethnicityonthebasisofvisualobservationorsurname.Ifyoudonotwishtofurnishthisinformation,pleasechecktheboxbelow.

Idonotwishtofurnishthisinformation.

Ethnicity

Hispanicyesno

RACE

White/CaucasianBlack/AfricanAmericanAsianAmericanIndian/AlaskanNative NativeHawaiian/OtherPacificIslander

Other

MaleFemale

Veteran–YesNo

Thisinformationwillalsoberequiredofemployeesiftherequestisapproved.

BORROWER’SCERTIFICATIONANDAUTHORIZATION

Certification

Theundersignedcertifythefollowing:

1.I/WehaveappliedforaloanfromPiscataquisCountyEconomic DevelopmentCouncil(“Lender’).Inapplyingfortheloan,I/wecompletedaloanapplicationcontainingvariousinformationonthepurposeoftheloan,theamountandsourceofthedownpayment,employmentandincomeinformation,andassetsandliabilities.I/Wecertifythatalloftheinformationistrueandcomplete.I/Wemadenomisrepresentationsintheloanapplicationorotherdocuments,nordidI/weomitanypertinentinformation.

2.I/WeunderstandandagreethattheLenderreservestherighttochangetheloanreviewprocesstoafulldocumentationprogram.Thismayincludeverifyingtheinformationprovidedontheapplicationwiththeemployerand/orthefinancialinstitution.

3.I/WefullyunderstandthatitisaFederalcrimepunishablebyfineorimprisonment,orboth,toknowinglymakeanyfalsestatementswhenapplyingforthisloan,asapplicableundertheprovisionsofTitle18.UnitedStatesCode,Section1001,etseq.

Piscataquis County Economic Development Council (PCEDC), 50 Mayo Street, Dover-Foxcroft, Maine 04426

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ToWhomItMayConcern:

AuthorizationtoReleaseInformation: I/WehaveappliedforaloanfromPiscataquisCountyEconomicDevelopment Council(“Lender”).Aspartoftheapplicationprocess,theLendermayverifyinformationcontainedinmy/ourloanapplicationandinotherdocumentsrequiredinconnectionwiththeloan,eitherbeforetheloanisclosedoraspartofitsqualitycontrolprogram.

1.I/WeauthorizeyoutoprovidetotheLenderandtoanyinvestortowhomtheLendermaysellmyloanandtotheguarantyinsurer(ifany),anyandallinformationanddocumentationthattheyrequest.Suchinformationincludes,butisnotlimitedto,employmenthistoryandincome;bank,moneymarket,andsimilaraccountbalances;credithistory;andcopiesofincometaxreturns.

2.TheLenderoranyinvestorthatpurchasestheloanortheguarantyinsurer(ifany),mayaddressthisauthorizationtoanypartynamedintheloanapplication.

3.Acopyofthisauthorizationmaybeacceptedasanoriginal.

4.YourpromptreplytotheLender,theinvestorthatpurchasedtheloanortheguarantyinsurer(ifany)isappreciated.

5.Guarantyinsurer(ifany):

Certification(AddendumtoApplication)

PursuanttotheDebtCollectionImprovementActof1996,theundersignedapplicantherebycertifiestothefollowing:

Neithertheapplicantoranystockholderorpartnerowing20%ormoreintheapplicantaredelinquentonanyFederalindebtedness.

IfApplicantisaProprietorofGeneralPartner,SignBelow:

By:Date:

IfApplicantisaCorporation,SignBelow:

By:Date:

Attestedby:Date:

GuarantorDateSocialSecurityNumber/TaxIDNumber

GuarantorDateSocialSecurityNumber/TaxIDNumber

PLFPROGRAMELIGIBILITYBASEDONINFORMATIONPROVIDED

SSBCI(FAME)REDLP(FAME)

IRPPLFUSDA

OTHER

LoanOfficerDate

Piscataquis County Economic Development Council (PCEDC), 50 Mayo Street, Dover-Foxcroft, Maine 04426

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