2209 River Road, Louisville, KY 40206
502/721-9446 - phone • 502/721-9776 - fax
877-548-2622 - toll free
1a. Customer Name(s) 1b. Entity Type 1b. SS or TIN 1c. Birthdate 1d. Year Began Farming 1e. Primary Ag Product
2. Mailing Address 3. Telephone Numbers 4. Email Address
2a. Length of Time at Address: Mobile:
5. Business Information
Liability Insurance: Crop Insurance: Current Lender:
Insurance Agent: Insurance Agent: Contact:
Address: Address: Address:
Address: Address: Address:
Telephone: Telephone: Telephone:
6. Description of Loan Requested
Operating Line of Credit Amount Due when?
Real Estate Loan Amount Term Amortization 1 Payments per Year 2
Equipment Term Maturity Payments per Year
Specific Purpose of Loan
7. Real Property Offered to Secure Real Estate Loan
Total Acres Property Address Title to vest in what name(s)?
Tillable Acres County, State
Pastured Acres Name of Public Road Title will be held as Sole/Joint Tenants/etc.
Mineral rights 100% owned? Yes No Accessible by public road? Dwellings on property? Is one your principal residence?Annual Lease Amount
Yes No Yes No Yes No Yes No (if leased)
Mineral rights leased?
8. Declarations, Representations and Warrants Applicant Co-Applicant
Yes No Yes No
A. Are there any outstanding judgements against you? If yes, explain:
B. Have you, or any entity in which you have greater than a 10% ownership, been declared bankrupt within the past seven years?
If yes, please indicate the type of bankuptcy, date of filing, and date of discharge, if any.
Chapter 7 ___ Chapter 11 ___ Chapter 12 ___ Chapter 13 ___ Date of Filing:
Date of Discharge:
C. Have you, or any entity in which you have greater than a 10% ownership, had property foreclosed upon or
given title or deed in lieu thereof in the last seven years? If yes, please explain:
D. Do you have MPCI Insurance or Federal Crop Insurance in force?
E. Did you have an MPCI or Federal Crop Insurance claim in the last five years?
If yes, which years: ___2005 ___2006 ___2007 ___2008 ___2009
F. Are you a U.S. citizen or a permanent resident alien?
G. Are you a guarantor of any debts that are not reflected on current balance sheet statement? If yes, please explain:
H. Do you have any accounts that are past due by 30 days or more? If yes, please explain:
Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who applies for a loan. Your name, address, date of birth, and other
information used to identify you will be verified. You may also be asked to provide your driver's license or other identifying documents prior to closing your loan. I/We authorize CGB
Agri Financial Services and its affiliated lenders ("Lender"), to make all inquiries deemed necessary to verify the accuracy of the information contained herewith to determine my/our
credit worthiness. I/We intend that all credit data we have submitted to Lender be considered as part of this application. The information contained in the application is provided for
the purpose of obtaining business (non-consumer) credit with the Lender on behalf of the undersigned. It is understood Lender will rely on the information provided in making its credit
decision. The undersigned warrants and represents the information herein submitted is true and correct in all aspects and Lender may consider this representation continuing until
written notice to the contrary is received by the Lender from the undersigned. The Lender is hereby authorized to answer any questions from third parties concerning the
undersigned's experience with the Lender. I/We further agree and consent that Lender may obtain an appraisal of, and evidence of title to and existing liens on, the property offered
as security and that I/we are responsible for the payment of all costs of obtaining this information. It is the policy of CGB Agri Financial Services to not disclose any non-public
personal information about you or your operation except as authorized by you or as required by law.
No commitment is binding unless confirmed in writing.
The Applicant represents and declares that the proceeds of the loan will be used solely for business purposes.
I HAVE READ, UNDERSTAND, AND AGREE TO MAKE THESE REPRESENTATIONS AND WARRANTS
If a Partnership, Corporation or other entity:
Date 20_____ By