Name of Borrower (Business Legal Name): Primary Business Contact:
Street Address: City/State/Zip:
County: Website Address:
Street Address of New Project: City/State/Zip:
County: E-mail address:
Telephone #: NAICS Code:
1) OWNERSHIP STRUCTURE: Proprietorship, partners, officers, directors, holders of outstanding stock. 10
percent or more of business ownership must be accounted for:
Name: Title: % of Ownership
List all affiliates and subsidiaries of the business:
Have there ever been judgments or injunctions against the business or owners? Yes No
If Yes, describe:
Is there pending litigation involving the business? Yes No If yes, attach summary and disposition.
Has the business or the owners of the business ever filed bankruptcy? Yes No If yes, describe:
2) BUSINESS STRUCTURE: Indicate type of business and provide verification:
Corporation: Articles of Incorporation, By-Laws, Certificate of Incorporation
Partnership: Partnership Agreement
LLC: Articles of Organization, Operating Agreement, Member Control Agreement, Certificate of
Proprietorship or operates under a name other than the businesses legal name : Assumed Name
Certificate, Affidavit of Publication
President: Vice President:
4) KEY EMPLOYEES:
Name: Title: Responsibilities: Years with
5) CURRENT EMPLOYMENT INFORMATION: Current Number of Full Time Equivalent (FTE) Employees
in Minnesota: Current Number of Full Time Equivalent (FTE) Employees on site:
*Full Time Equivalent is based on a total annual hours of 2080
6) JOB CREATION FORM: Required with completed application. A payroll report must also be submitted.
7) FINANCIAL INFORMATION:
Primary Bank of Account: Contact Person:
Phone #: E-mail:
8) RESUMES & PERSONAL FINANCIAL STATEMENTS: Resumes as well as current (past 90 days), dated
and signed personal financial statements on all 10 percent or more of business ownership should be provided.
9) PROJECTIONS: Provide 2 years proforma balance sheets, income statements and cash flows. Define the
assumptions used to derive the projections.
10) COLLATERAL: Provide a list of all collateral offered, new and existing, its value, and security position by
funding source. Personal guarantees will be required from persons with 10 percent or more of business
11) PROJECT COSTS: Provide cost estimates which must include the total project and be equal to the uses of
funds. Some of the cost may include machinery and equipment – vendor quotes, Real Estate – appraisal,
Construction – contractor cost estimate. Other costs should be included as well.
12) PROJECT TIMEFRAME:
Task: Estimated Completion Date:
Commitment of all funds
Start of construction
13) SOURCE AND USE STATEMENT:
MIF Bank(s) Equity Local Other Total
Renovation of an
Purchase of Machinery
Sanitary Sewer / Water
Total Project Cost
PERSONAL GUARANTEES ARE REQUIRED AS A CONDITION OF THE MIF LOAN.
A) Are there any environmental risks associated with the site, building, or the business itself?
B) Will the project result in the loss or diminution of wetlands? Yes No If yes, describe the
measures which will be taken to mitigate all functional values of the wetlands that will be lost or
C) Will the proposed project be located in a flood plain? Yes No If yes, is flood insurance
required? Yes No
D) Have state environmental review requirements been met, if applicable? Yes No
The data you supply in this application to the Minnesota Department of Employment and Economic Development will
be used to assess your company’s qualifications for a business loan. We will not be able to process the application
without this information. If an award is provided for the project, the information contained in the application will
become a matter of public record with the exception of those items protected under the Minnesota Government Data
Practices Act found in Minnesota Statutes 1997, Chapter 13.
I have read the above statement and I agree to supply the information requested to the Minnesota Department of
Employment and Economic Development, Division of Business and Community Development with full knowledge of
the information provided herein. I certify the information contained herein is true and accurate.
Signature of Company Official Position