Albany Community Together, Inc

1

Albany Community Together, Inc. (ACT!)

Business Loan Application

Client Id #: _____

Income Level: _____

Update Date: _____

Application Date: ___/___/___

LAST NAME: ______FIRST NAME: ______MI: ______
BUS. NAME: ______BUS. PHONE: ______BUS. FAX: ______
BUS. ADD. (CITY, STATE ZIP): ______
EMAIL:______WEB ADD:______In business since:_________
PREVIOUS BUS. ADD. (CITY, STATE ZIP): ______
Business Tax ID Number:______
Type of Business(existing or proposed):______
Names of Subsidiaries/Affiliates:______
BUSINESS PARTNER INFORMATION Partnership Information:(Use additional sheet for other partners)
Is this business a partnership? __Yes __No First Name: ______Last Name: ______
Type of partnership __Legal __Informal (City, State Zip): ______
______
Home Phone:______Fax Phone: ______
EmailAdd: ______
BUSINESS FEATURES
Is this a woman-owned business? □ Yes □ No Is this a minority-owned business? □ Yes □ No
Is this a veteran-owned business? □ Yes □ No Is this a home-based business? □ Yes □ No
Are you engaged in import/export trade? □ Yes □ No Is this business full-time or part-time? □ FT □ PT □ Seasonal
□ American Indian/Alaskan Native □ Hispanic/Latino □ White □ Asian □ African American □ Native Hawaiian/Pacific Islander □ Other
Do you have any of the following? (Please check all that apply)
□ Business License □ Sellers Permit/Retail # □ Registered DBA □ Patent □ Trademark □ Copyright □ Business Plan
BUSINESS FORM:
□ Sole Proprietorship □ Partnership □ Corporation □ S-Corporation □ Limited Liability Company
FINANCE INFORMATION
How much bank or personal funding has been committed for this project to date: $______
Amt Requesting from ACT! $______Proposed use of Funds:______
Source of Other financing: □ Family/Friend □ Private Investor □ Government Loan □ Bank Loan □ Personal Savings □ SBA Loan □ Trickle Up Grant □ Individual Development Account □ Other (specify)
Last years gross sales: $ ______Does your business provide: □ Supplementary Income □ Sole Source Income
Net Profit/Loss: $ ______What is your income goal? □ Supplementary Income □ Sole Source Income
In the last year, did your business provide for an owner’s draw/salary? □ Yes □ No Amount of draw/salary: $ ______
Bank of Business Account (w/complete address):______
EMPLOYEE INFORMATION
Do you have employees? □ Yes □ No
If Yes, total number of employees in year:
Full-Time: ___ Part-Time: ___
Seasonal/Temp: ___ .
______Date: ______
Signature
SECTION II
USES OF FUNDS STATEMENT
+Please include proposed uses of loan funds requesting from ACT!
USE OF PROCEEDS: / LOAN REQUESTED:
(ENTER GROSS DOLLAR AMOUNT)
ROUNDED TO NEAREST HUNDREDS
LAND/BUILDING ACQUISITION
NEW CONSTRUCTION/RENOVATION
ACQUISITION OF MACHINERY/EQUIPMENT
FIXTURES/SIGNAGE
INVENTORY PURCHASE
WORKING CAPITAL (INCLUDING ACCOUNTS PAYABLES)
ACQUISITION OF EXISITING BUSINESS
ALL OTHERS
TOTAL LOAN REQUESTED
TERM OF LOAN REQUESTED
NAME & OCCUPATION / MAILING ADDRESS / TOTAL FEES PAID / FEES DUE
$ / $
$ / $
$ / $
$ / $
Please provide the following information for all consultants/advisors paid to assist with this application:
______
SIGNATURE OF PREPARER (S) IF OTHER THAN APPLICANT IF APPLICANT IS A PROPRIETOR OR GENERAL
PARTNER (S), SIGN HERE
______
______
IF APPLICANT IS A CORPORATION, SIGN HERE
BY: ______ATTESTED BY: ______
SIGNATURE OF PRESIDENT SIGNATURE OF CORPORATE SECRETARY
I AUTHORIZE Albany Community Together, Inc. (ACT!) to obtain a credit report on me through the credit-reporting agency of its choice. If an adverse credit decision is made due to totally or partly to the information on the credit report, ACT! Will identify the source of the credit report, so that I may contact them if I wish.
Name (Printed): ______Name (Printed): ______
Signature: ______Signature: ______
Date: ______Date: ______
SECTION III
Previous ACT! or other Government Financing: If you, any principals, or affiliates have ever requested Government Financing, complete the following:
Name of
Agency / Original Amount
of Loan / Date of Request / Approved
or
Declined / Balance / Current or Past Due
SECTION IV
Furnish the following information on all installment debts, contracts, notes, and mortgage payable. Indicate by an asterisk (*) items to be paid by loan proceeds and reason for paying same (present balance should agree with latest balance sheet submitted).
To
Whom Payable / Original Amount / Original Date / Present Balance / Rate of Interest / Maturity Date / Monthly Payment / Security / Current
Or
Past Due
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
MANAGEMENT (Proprietor, partners, officers, directors, and all holders of outstanding stock – 100% OF OWNERSHIP MUST BE SHOWN).
Name, Social Security # / Mailing Address (Complete) / % Owned / Position
Held
Attach supplental sheet if necessary.