Applicant Business Legal Name
Operating Business Legal Name
DBA or Tradename (if applicable)
Business Phone
Year Began Operations
Business Address (Street, City, State, Zip Code)
Primary Contact's First Name
Primary Contact's Last Name
Primary Contact Email Address
Middle Credit Score
Purpose of the Loan
Acquisition/installation of Equipment
Working Capital
Business Acquisition (Change of Ownership)
Purchase/Construction of Commercial Real Estate
Acquisition of Inventory
Debt Refinancing
Other
Owner's Legal Name
Title
Ownership %
TIN (SSN/EIN)
Home Address
Owner's Legal Name (First and Last Name)
Owner's Position
Cash on Hand & in Banks
Savings Account
IRA or Other Retirement Account
Accounts & Notes Receivable
Life Insurance - Cash Surrender Value Only
Stock and Bonds
Real Estate
Automobiles
Other Personal Property
Other Assets
Total
Accounts Payable
Notes Payable to Banks and Others
Installment Account (Auto)
Mo. Payments
Installment Account (Other)
Mo. Payments
Loan(s) Against Life Insurance
Mortgages on Real Estate
Unpaid Taxes
Other Liabilities
Total Liabilities
Net Worth
Total
Salary
Net Investment Income
Real Estate Income
Other Income (Describe Below)
As Endorser or Co-Maker
Legal Claims & Judgments
Provisions for Federal Income Tax
Other Special Debt
Type of Real Estate (e.g. Primary Residence, Other Residence, Rental Property, Land, etc.)
Address
Date Purchased
Original Cost
Present Market Value
Name & Address of Mortgage Holder
Mortgage Account Number
Mortgage Balance
Amount of Payment per Month/Year
Status of Mortgage
Type of Real Estate (e.g. Primary Residence, Other Residence, Rental Property, Land, etc.)
Address
Date Purchased
Original Cost
Present Market Value
Name & Address of Mortgage Holder
Mortgage Account Number
Mortgage Balance
Amount of Payment per Month/Year
Status of Mortgage
Type of Real Estate (e.g. Primary Residence, Other Residence, Rental Property, Land, etc.)
Address
Date Purchased
Present Market Value
Original Cost
Name & Address of Mortgage Holder
Mortgage Account Number
Mortgage Balance
Amount of Payment per Month/Year
Status of Mortgage
Broker Full Name
Broker Fee
Broker Email
Broker Phone Number
