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Justine PETERSEN's Micro-Loan Application - Justine Petersen

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Justine PETERSEN's Micro-Loan Application - Justine Petersen Powered By Docstoc
					                                        JUSTINE PETERSEN
                                     MICRO-LOAN APPLICATION
DATE

BORROWER NAME:                                                 CO-B ORROWER:

ADDRESS:                                                       ADDRESS:

CITY, STATE ZIP                                                CITY, STATE ZIP

PHONE:                                                         PHONE:

SOCIAL S ECURITY # :                                           SOCIAL S ECURITY # :

E-MAIL:                                                        E-MAIL:


                                          BUSINESS INFORMATION

B USINESS NAME:                                                                _COUNTY:

B USINESS ADDRESS:

B USINESS PHONE:                                                       WEBS ITE:

B USINESS S ECTOR / S UMMARY OF B US INESS ACTIVITIES:

       ______________________________________________________________________YEARS EXPERIENCE:


TYPE OF B US INESS:     PROPRIETORSHIP PARTNERS HIP  CORPORATION                       LLC  OTHER:

                        EXIS TING: a) WHEN STARTED?
                                    b) B US INESS SALES IN B ES T MONTH:         MONTH
                                    c) B US INESS SALES IN WORST MONTH          MONTH
                                    d) ANNUAL DRAW FROM THE B US INESS?  ___________________________
                                    e) YEAR ROUND EMPLOYEES: # FULL TIME        # PART-TIME________
                                    f) S EASONAL EMPLOYEES : # FULL TIME # PART-TIME _______________

                        NEW                    100% WOMAN OWNED              51% WOMAN OWNED

HOW MUCH TIME DO YOU CURRENTLY SPEND ON THIS B US INESS?

HOW MUCH TIME DO YOU PLAN TO SPEND ON THIS B US INESS?

HOW MUCH OF OWN RES OURCES HAVE YOU US ED TO START AND/ OR OPERATE THIS B US INESS?


                              DEMOGRAPHIC INFORMATION (OPTIONAL)

FEMALE HEAD OF HOUS EHOLD?  YES                NO            VIETNAM VET ERAN?                YES         NO
                                                               OTHER VET ERAN?                  YES         NO
GENDER:       Female Male

ETHNICITY:  Alaskan Nati ve/ Eskimo/Alui t   American Indian                 Asian or Asian American
 Asian or Asian American- other               Black- African American         Black- other
 Latino or Hispanic              Latino or His panic- other  Mi ddle Eas tern        Pacific Islander
 White Caucasian Euro-American not of Latino origin            Bi-Raci al or Multi-Raci al    Other
                      EMPLOYMENT (IN ADDITION TO SELF-EMPLOYM ENT)

BORROWER EMPLOYER:                                                   CO-B ORROWER EMPLOYER:

ADDRESS:                                                             ADDRESS:

CITY, STATE ZIP                                                      CITY, STATE ZIP

WORK PHONE:                                                          WORK PHONE:

JOB TITLE:                                                           JOB TITLE:

HOURLY SALARY:$                # HOURS/ MONTH                        HOURLY SALARY:$             # HRS/MO

DATES OF EMPLOYMENT:                                                 DATES OF EMPLOYMENT:


                                     ANNUAL HOUSEHOLD INCOME

NAME                              AGE       MONTHLY INCOME                 SOURCE




    CHILD SUPPORT, SOCIAL SECURITY, SSI, VA BENEFITS, INTEREST INCO ME, ANNUITIES MAYBE USED AS INCOME

HOUS EHOLD S IZE:                            TOTAL HOUS EHOLD INCOME $

ARE YOU CURRENTLY RECEIVING: a) TANF B ENEFITS? ______ b) ANY OTHER PUB LIC ASSISTANCE? _______

DO YOU HAVE HEALTH INS URANCE FOR YOURS ELF OR OTHER HOUS EHOLD MEMB ERS?

IF YES, PLEAS E SPECIFY SOURCE:

                                        LANDLORD INFORMATION

HOME LANDLORD’S NAME                                                         PHONE:

TIME AT CURRENT RES IDENCE: YEARS:                    MONTHS                 FAX:

B USINESS LANDLORD’S NAME                                                    PHONE:

TIME AT CURRENT RES IDENCE: YEARS:                    MONTHS                 FAX:


                                         PERSONAL REFERENCES

NAME:                                                                NAME:

ADDRESS:                                                             ADDRESS:

CITY, STATE ZIP                                                      CITY, STATE ZIP

HOME PHONE:                                                          HOME PHONE:
                                                FINANCIAL INFORMATION

                        Personal Financi al Information                      Business Financial Information


               Income                                                  Business Income projected        actual 
               Income fro m self-emp loy ment                          Gross Sales
               W2 employ ment inco me                                  Other inco me
               Spouse's income                                         Total Business Income
               Other inco me
               Total Personal Income                                   Business Expenses
                                                                       Materials, merchandise
               Personal Expenses                                       Salaries, Labor
               Ho me rent/ mortgage payment                            Insurance, Gasoline
               Vehicle and other loan
               payments                                                Utilit ies
               Cred it Card pay ments                                  Business rent/mortgage
               Food & Clothing                                         credit card pay ments
                                                                       vehicle and other loan
               Utilit ies                                              payments
               Insurance                                               Total Business Expenses
               Gasoline                                                Gross Business Surplus
               Total Household Expenses                                Owner's Draw
               Personal Surplus                                        Net B usiness Surplus

                                                     LOAN SPECIFICS

HOW MUCH WOULD YOU LIKE TO B ORROW?

HOW DO YOU INTEND TO US E THIS MONEY?                         WORKING CAPITAL                     MATERIALS  SUPPLIES

 EQUIPMENT                          INVENTORY               FURNITURE            FIXTURES            MACHINERY

LIST SPECIFIC US E(S ):



HOW MUCH CAN YOU AFFORD FOR YOUR MONTHLY PAYMENT?

Will loan funds all ow you to hire additional employees and if so, how many?______________________

Will you recei ve addi tional sources of capi tal (loan or grant) for this project?  YES        NO

        If so please describe:


                                                          CO-SIGNER(S)

NAME:                                                                          NAME:

ADDRESS:                                                                       ADDRESS:

CITY, STATE ZIP                                                                CITY, STATE ZIP

HOME PHONE:                                                                    HOME PHONE:
                                                                         COLLATERAL

WHAT DO YOU PLAN TO US E AS COLLATERAL?___________________________________________________

REAL ES TATE                                                                                                       VEHICL E

PROPERTY ADDRESS:__________________________                                                            Year:_____ Make:____ Model:______
# OF TOTAL ROOMS (NOT INCLUDING B ATHROOM):_________                                                   Type of editi on (coupe, sedan)_____
# OF B EDROOMS:_________ # OF B ATHROOMS:_________                                                     Miles:__________
UPDATES :___________________________________________                                                   Standard or Fully loaded:________
Is there a garage?________ One or two car?________                                                     What is the conditi on of vehicle?
Attached or detached?____________                                                                      ___Excellent ___Good
Is there a basement?______                                                                             ___Fair ___Poor
Is basement finished, unfinished, parti ally?_______                                                   Es timated val ue:_________________
Es timated property value?_____________
What is the property condi tion?
 ____Excellent ___Good ___Fair ___Poor
Outstandi ng Liens?________

                                                                CREDIT INFORMATION

     1.     Do you have a Bank Account? Yes  No

     2.    Have you ever filed for bankruptcy?  Yes  No
           If you presently have an active bankruptcy you do not qualify for a loan under our program guidelines. If you hav e
           successfully co mpleted your bankruptcy plan, please provide us with your discharge papers.

     3.    Are you delinquent on your child support payments? Yes  No
           If you presently show past due child support accounts you do not qualify for a loan under our program guidelines. If you are
           under a payment plan and in co mpliance with it, please provide us with proof of pay ments.


I attest that all of the information on this application is true. I authorize Justine Petersen to investigate and verify the above
informat ion and contact any references regarding this application. I also authorize Justine Petersen to perform a credit che ck, which
will include obtaining a consumer cred it report and exchanging informat ion about credit experiences with other creditors fro m time to
time, as authorized by law.

Signature of Borro wer:                                                                                             Date:

Signature of Co-Borro wer:                                                                                          Date:

Please Attach:
    1. $25.00 Applicat ion Fee (includes credit report)
    2. Business Plan or co mp leted Business Plan Questionnaire
    3. Photo ID of each applicant
    4. Last paystub from emp loy ment outside of the business for each applicant
    5. Last three bank statements
    6. Last two years of personal tax returns, including the Schedule C if applicab le
    7. Last two years of federal tax returns, if applicab le
    8. Business Lease (if renting space)

Return completed application and attachments to:
Justine Petersen, Attn: Dan Montrey, 1023 N. Grand Blvd, St. Louis, MO 63106 o r d montrey@justinepetersen.org

For Technical Assistance completing a Business Plan Questionnaire or applicati on contact:
IDA/ Loan Fund Manager, Aida Ibragimova, at (314) 533-2411 ext . 118 o r aib ragimova@justinepetersen.org

                                                               EQ UAL CREDIT O PPORTUNITY ACT
The Federal Equal Opportunity Act prohibits creditors from discriminating against applicants on the basis of race, color, religion, national origin, sex, marital status,
age, because all or part of the applicant’s income derives from any public assistance program or because the applicant has in good faith exercised any right under the
Consumer Credit Protection Act.