"SBA Microloan Application - Application.doc"
VEDC SBA Microloan Application Package Business Information An incomplete application package will not b e processed. Business Name: _______________________________________________________ SIC CODE ___________________ Business Address: _________________________________________________City: _______________________________ State: ________ Zip Code: ________________Telephone: ________________________ Fax: _______________________ Business Structure (Circle One) : Sole Proprietor Partnership Joint Venture Other _______________________ Corporation (TYPE): ______________ State Incorporated ____________________________ Brief Business Description: ______________________________________________________________________________ ________________________________________________________________________________________________ ____ State Tax Cash $ _________________ Land Value $ _________________ ID In-Kind Contribution $ _________________ Other (Describe) $ _________________ $ __________________ (Busines B. Total Equity Contribution (B) s License Number): _____________________________Federal Tax ID: ________________________ Date Business was established: ______/______/______ Bank Business Account Es tablished (Include Branch Address): ________________________________________________________________________________________________ ____ Project Financing A. Microloan Request $_____________________ (A) B. Applicant Equity Contribution C. Total Cost of Project (A + B = C) $_____________________(C) Purpose of Loan ______________________________________________________________________________________ Source of Repayment: _________________________________________________________________________________ Page 1 Use of Funds Microloan Funds + Other Funds = Total Inventory Capital Machinery Equipment Fixed Tenant Improvements Professional Fees Working Capital Rehabilitation _____________________Other : T otal: + = Public Benefit As a direct result of receiving the SBA Microloan Funds, will your project: Increase Employment Opportunities? ________ Retain Jobs?________ Provide Goods & Services Presently Unavailable?_______ How Many Jobs Will You Create? ______ Summary of Collateral Present Market Value Mortgage Liens Equity Commercial Real Estate $ _________________ $ __________________ $ __________________ Residential Real Estate $ _________________ $ __________________ $ __________________ Machinery & Equipment $ _________________ $ __________________ $ __________________ Other ______________ $ _________________ $ __________________ $ __________________ Total $ _________________ $ __________________ $ __________________ Outstanding Business Debt Original Amount Account Number Maturity Date To Whom Payable Interest Monthly Collateral Held Current Balance Date of Loan Rate % Payment 1. $ $ $ 2. $ $ $ 3. $ $ $ 4. $ $ $ 5. $ $ $ 6. $ $ $ Page 2 Business Site Control Does applicant have control of site? Yes No If YES, indicate type of control: Own Lease Type of Lease_________________________________ Is Lease Assumable? Yes No Terms of Lease _______________________________ Renewal Options ___________________________________ Management Include anyone holding 20% or more of stock: Proprietors, Partners, Officers, Directors, and Stockholders. These same individuals must also complete the Personal Financial Statement (Attached) Name Percentage of Ow nership Annual Compensation $_________________ 1. _____________________________________________ _______ _ $_________________ 2. _____________________________________________ _______ _ $_________________ 3. _____________________________________________ _______ _ $_________________ 4. _____________________________________________ _______ _ Management Training (Entrepreneurial Training or Business Development Workshops) Name of Program Date Completed 1. _______________ _________________________________________________________________________ _ _ 2. _______________ _________________________________________________________________________ _ _ Page 3 References Contact Name Address, City, State, Zip Phone Number Business References: 1. ( ) 2. ( ) 3. ( ) Personal References: 1. ( ) 2. ( ) 3. ( ) CHECKLIST Please complete as directed and sub mit along with requested information. An incomplete application package wi ll not b e processed. All tax returns and financial information must b e signed and dated. For All Applicants: Signed and Completed VEDC SBA Microloan Application Signed and Completed Personal Financial Statement [from each person owning 20% or more of the business] Copy of 3 years Personal Tax Returns [ from each person owning 20% or more of the business] Signed Credit Authorization [ from each person owning 20% or more of the busines s] Copy of Driver License [ from each person owning 20% or more of the business] In Addition to the Following, As Applicable For Businesses 1 Year Old and Older Executive Summary (Brief History of Operations and Management) Copy of the past 3 years Business Tax Returns with all attachments and schedules (if incorporated) Interim Business Financial Statement One Year Monthly Projections For Businesses Younger Than 1 Year Complete Business Plan Interim Business Financial Statement 3 Years Monthly Projections CERTIFICATION It is hereby represented and certified by the undersigned that to the best knowledge and belief of the undersigned, the information contained herein and attached hereto is accurate and correct and truly descriptive of the project, the Applicant and any guarantor or other proposed project occupant. Applicant Name: __________________________________________________ (Please Print) Applicant Signature: _______________________________________________ Date: _____________________ Page 4 5121 Van Nuys Boulevard, 3 rd Floor, Van Nuys, CA 91403 Phone (818) 907-9977 Fax (818) 205-1782 VEDC SBA Microloan Program Individual Financial Statement To Be Completed b y All Management holding 20% or more of stock: Proprietors, Partners, Officers, Directors & Stockholders. ________________________________________________________________________________________________________________ ___________ Last Name First Initial Date of Birth Social Security No. Driv er License No. ________________________________________________________________________________________________________________ ___________ Street Address City , State, Zip Phone ________________________ □ Own □ Rent $___________________ □ Married □ Unmarried □ Separated How Long Liv ed: Y ears/Months. Monthly Pay ment ________________________________________________________________________________________________________________ ___________ Current Employ er Address City , State, Zip Phone ________________________________________________________________________________________________________________ ___________ Position Y ears/Months Monthly Salary Prev ious Employ er Y ears/Months ________________________________________________________________________________________________________________ ___________ Name of Spouse/Co-Applicant Date of Birth Social Security No. Driv er License No. Phone ________________________________________________________________________________________________________________ ___________ Address of Spouse/Co-Applicant City , State, Zip _______________________________________________________________________________________________________ _________ ___________ Name and Address of Spouse’s Employ er City , State, Zip Phone ________________________________________________________________________________________________________________ ___________ Position Y ears/Months Monthly Salary Please complete Schedules A-E on the following pages then use information in those sections to complete below. Page 5 ASSETS AMOUNT LIABILITIES AMOUNT Cash in Bank $ Mortgages or Liens on Real Estate (Schedule C) $ Salary or Wages $ Property Taxes $ Other Institutions $ Revolving Credit (Schedule D) $ Securities/ Interest $ Income Taxes $ $ Installment Contracts & Notes Payable (Schedule E) $ Rentals $ Payments on loans and contracts $ Listed Stocks and Bonds (Schedule A) $ Income Taxes Payable $ Business $ Medical Expenses $ Unlisted Stocks and Bonds (Schedule A) Other Income (Describe) $ Other Taxes Payable Expenses $ $ Estimated Living $ Notes Receivable (Schedule B) $ All Other Liabilities (Itemize) $ $ Insurance Premiums $ Real Estate Ow ned (Schedule C) $ $ $ $ IRA/Keogh/Pension $ $ Total Annual Income $ Tax Return AGI $ Other Investments $ $ Automobiles $ $ $ $ Cash Value Life Insurance (F) $ $ Other Assets (Itemized) $ Total Liabilities (B) $ $ Net Worth (A-B) $ Total Assets (A) $ Have you made a will? ___________ Executor? _______________________________________________________ Your Attorney_______________________________________ Your Accountant____________________________________ Life Insurance Face Amount: $________________________ Cash Value: $______________________________( F ) Beneficiary: ____________________________________ Personal Property Insurance: $____________________________ Continued from page 4 (You do not have to list income from alimony, child support or maintenance unless you want the Lender to consider it for the purpose of this application for credit.) Contingent Liabilities Are You Co-Signer on Any Loans? __________ Number of Loans _____ Amount of Liability $___________________ Any Lawsuits or Judgments Pending? $_________________________ (Other) $____________________________ General Information If married, these questions apply to both you and your spouse Are any assets held in Trust? Yes____ No____ Have you ever had a bankruptcy or a judgment against you? Yes____ No____ Have you been a principal or guarantor of a firm that declared bankruptcy? Yes____ No____ Have your tax returns ever been questioned by the I.R.S.? Yes____ No____ If Yes, the most recent year: _____________ Situation settled? Yes____ No____ Are any assets pledged or debts secured except as shown? Yes____ No____ Page 6 Have you ever had a repossession or foreclosure? Yes____ No____ Are you a party of any claim or lawsuits? Yes____ No____ Do you have a criminal record? Yes____No____ If you answered yes to any of the above, please explain. (Attach separate sheet if necessary.) ________________________ ________________________________________________________________________________________________ ____ ________________________________________________________________________________________________ ____ Are you a U.S. Citizen? Yes____ No____ If No, Alien Registration Number ______________________________ [Please provide a copy of Front & Back of registration card] Stocks And Bonds (Schedule A) Do You Own 10% or more of the outstanding share of any company? Y N Any of your securities restricted? Y N * How No. Shares or Description Title in Name of Pledged Where Traded Present Mkt. Held Bond Amount (Y/N) Value * Indicate J-Jointly with Spouse; O-Jointly with other than Spouse; A-Applicant's separate property; Total $ S-Spouses separate property Notes Receivable (Schedule B) * How Collateral/Type of Date of Annual P & I 1st or 2nd Name of Debtor Due Date Unpaid Balance Held Property Note Payment Lien * Indicate J-Jointly w ith Spouse; O-Jointly w ith other than Spouse; A-Applicant's separate property; S-Spouses separate property TOTAL Real Estate Owned - Mortgage Or Liens (Schedule C) Page 7 c. Date of a. 1st Monthly a. Market Value *How ** Purchase Balance Payment Property Address Name of Lender Held Type b. 2nd Monthly b. Cost d. % Ow ned Balance Payment a. c. 1st a. b. d. 2nd b. a. c. 1st a. b. d. 2nd b. TOTALS a. TOTALS a. b. b. * Indicate J-Jointly w ith Spouse; O-Jointly w ith other than Spouse; A-Applicant's separate property; S-Spouses separate property ** TYPE: Indicate SD (Single Dw elling); MD (Multiple Dw elling); C (Commercial/Industrial) Personal Revolving Credit (Schedule D) Creditor's Name Account No. Monthly Payment Present Balance 1. ____________________________ $____________ $________________ ___________________________________ __ _ 2. ____________________________ $____________ $________________ ___________________________________ __ _ 3. ____________________________ $____________ $________________ ___________________________________ __ _ 4. ____________________________ $____________ $________________ ___________________________________ __ _ 5. ____________________________ $____________ $________________ ___________________________________ __ _ 1. ____________________________ $____________ $________________ ___________________________________ __ _ 2. ____________________________ $____________ $________________ ___________________________________ __ _ 3. ____________________________ $____________ $________________ ___________________________________ __ _ 4. ____________________________ $____________ $________________ ___________________________________ __ _ Installment Contracts and Notes Payable (Schedule E) (Student Loans, Auto Loans, SBA Loans) The undersigned, for the purpose of procuring and establishing credit f rom time to time w ith you and to induce you to permit the undersigned to become indebted to you on notes, endorsements, guarantees or otherw ise, furnishes the follow ing as being a full, true and correct st atement of the financial condition of the undersigned on the above data, and agrees to notify you immediately of the extent and character of any material change in said financial condition, and also agrees that if the undersigned, or property of the undersigned held by you, be attempted to be obtained or held by w rite of execution, garnishment, attachment, or other legal process, or if any of the representations made prove to be untrue, or if t he undersigned fails to notify you of any material changes as above agreed, or if the business or any interest ther ein of the undersigned is sold, then and in such case, at your option all the obligations of the undersigned to you, or held by you, shall immediately become due and payable, w ithout demand or notice. This statement shall be construed by you to be a continuing statement of the condition of the undersigned, and a new and original statement of all assets and liabilities upon each and every transaction in and by w hich the undersigned hereafter becomes indebted to you, until the undersigned advises in w riting to the contrary. I assure you that all the information furnished is complete and correct. You may verify any of this information. I understan d that from time to time, you may receive information from others and you w ill answ er questions and requests from others seeking credit experience information about my account. I understand I may apply for credit in my name alone w ithout my spouse or any other person, regardless of my sex or marital s tatus. ___________________ _________________________________________________ _____________________________________________ Date Applicant Name (Please Print) Applicant Signature Page 8 ___________________ _________________________________________________ _____________________________________________ Date Spouse Name (Please Print) Spouse Signature Page 9