Submit by Email
Print Form
BUSINESS LOAN APPLICATION
How did you hear about ACCION USA? _______________________________________________
I. Personal Information
Name: ____________________________________ SS #: _____-____- _____ Date of Birth: (mm) ___ / (dd) ___ / (yy) _____ Country of Birth: __________________ How many people do you live with? (Spouse, children, relatives): _______________ Home Address: ____________________________________ City: ______________ State: _____ Postal Code: ___________ Home Phone #: (____) _____________ Cellular Phone #: (____) _____________ Email Address: _______________________ Length of Time at Address: ___ Yrs. ___ Mos. Do you: Own Rent No Rent a Room Yes Type: Other: _____________ Checking Savings Monthly Rent/Mortgage Payment: $________ Landlord Name: ________________________ Landlord #: (____) ___________ Do you have a personal savings or checking account in a bank or cooperative? Name of Bank or Cooperative: _______________________________________________________ Balance $______________
II. Business Information
Business Name: _________________________________________________________________________________________ Description of Business: __________________________________________________________________________________ Business Address: __________________________________ City: ________________ State: _____ Postal Code: __________ Business Phone #: (____) _____-______ Business Fax #: (____) _____-_______ Website: _____________________________ Monthly Bus. Rent: $_______ Bus. Landlord Name: _________________________ Bus. Landlord #: (____) _____-______ Years of experience in the field/industry: ___ Yrs. ___ Mos. How long have you owned the business? ___ Yrs. ___ Mos. Amount invested in the business: $_______ Number of employees (incl. owner): Full-time: ___ Part-time: ___ Sole Proprietor Corporation/LLC Cooperative Partnership (Names of Partners): _________________ Ownership: ___________________________________________________ Other __________________________________________ Business Location: Storefront Home No Office Yes Market Street Taxi Other _____________________ No Records Kept Financial Records Kept: Professional Accounts Regular Records Some Records
Do you have a business bank account? Amount
Bank: _____________________________________ Balance $_______
III. Loan Request (maximum $25,000)
Loan Purpose / Use of Funds (Break down how you will use the money)
$ $ $
Monthly Payment: What monthly payment could you afford for this loan? $________ Co-borrower: If required, could you provide a co-borrower for this loan? Yes No Possibly Who: ____________
IV. Credit History
Are you current on your rent, mortgage, and utility payments for your home and business? Are you aware of any tax liens placed against you or your business? Yes No Yes No
Please explain any late payments or tax liens: _________________________________________________________________
_________________________________________________________________________________________
ACCION USA 56 Roland St. Suite 300 Boston, MA 02129 Tel (866) 245-0783 Fax (877) 787-2574 www.accionusa.org
V. Financial Information
1. How much are your monthly business sales? 2. How much are your monthly business expenses? 3. List all sources of personal income: a. Monthly salary from the business: b. Monthly income of spouse/other household members: c. Other sources of monthly income:
(For example: other jobs, Social Security, pension, disability, public assistance, rental income, etc.)
1. $________________ 2. $________________
(Rent/mortgage, business loans & credit cards, materials/inventory, marketing, insurance, employees, utilities, and other expenses)
a. $________________ b. $________________ c. $________________ 4. $________________ 5. $________________ 6. $________________
4. How much are your monthly household expenses? 5. How much are your total monthly debt payments for your home and business?
(Loans - auto, personal, business, student, etc.; mortgage; home equity; credit cards; etc.)
(Rent/mortgage, personal loans & credit cards, food, transportation, utilities, insurance, education, childcare, recreation, and other expenses)
6. What is the total balance of outstanding debt for your home and business?
(Loans - auto, personal, business, student, etc.; mortgage; home equity; credit cards; etc.)
VI. Collateral
Please list the items that you could pledge as collateral (items or assets you own that are completely paid off that could secure your loan –
Ex. autos, equipment, electronics, computers, machinery):
Collateral (brand/manufacturer, model, year, serial number, etc.) $ $ $ $
Resale Value
VII. References (Please provide two professional and two personal references)
Name and company of supplier or client: ______________________________________ Telephone #: (____) _____-________ Name and company of supplier or client: ______________________________________ Telephone #: (____) _____-________ Name of family member or close friend: ______________________________________ Telephone #: (____) _____-________ Name of family member or close friend: ______________________________________ Telephone #: (____) _____-________
One of our loan officers will be contacting you shortly to follow up on your application. Please indicate the best time and telephone number at which to locate you: Phone #: (____) _____-________ Day and Time: _________________________
Thank you for applying to ACCION USA.
Please mail or fax this application to the number and address listed below. AUTHORIZATION FOR VERIFICATION OF INFORMATION PLEASE READ CAREFULLY BEFORE SIGNING APPLICATION:
I understand that this Loan Application may serve as the first step of a loan application and that ACCION USA may request supporting documents to verify the information provided. As part of the application process, I authorize ACCION USA to investigate and verify all of the above information. I authorize ACCION USA to perform a credit check, now or in the future, including obtaining consumer and/or commercial credit reports and to exchange information about credit experience with other creditors, from time to time, as authorized by law including retrieving a copy of my personal credit report. I also understand that the information provided on this Form or on my credit report may be used by ACCION USA to either approve or decline my request for credit and that I may be required to provide other information in addition to this application. The release in any manner of all information by ACCION USA is hereby authorized whether such information is of record or not, and I hereby release all persons, agencies, firms, companies, etc., from any damages resulting from such information.
__________________________ Applicant’s Signature
____ / ____ / ____ Date
________________________________ Business Partner/Co-borrower
____ / ____ / ____ Date
ACCION USA 56 Roland St. Suite 300 Boston, MA 02129 Tel (866) 245-0783 Fax (877) 787-2574 www.accionusa.org