Www.petromac.com
BUSINESS LOAN APPLICATION
For information and assistance, please contact:
|Sales Contact: | | |
|Telephone: | | |
|Fax: | | |
|Address: | | |
ADVANCE NOTICE OF TYPICAL SBA-GUARANTEED LOAN REQUIREMENTS
If your loan application is approved, you must comply with specific requirements. While they may not be fully known until the U.S. Small Business Administration (hereinafter "SBA") issues its loan authorization, you should anticipate the typical requirements addressed below. Alert your attorney, Realtor, and other professional advisors as soon as possible to the likelihood of these requirements. They will then be prepared to assist you when you initiate appropriate preliminary activity.
From issuance of the SBA Loan Authorization until the loan closing and first disbursements can be done in as little as 2-3 weeks. Unnecessary delays in your compliance with the requirements can cause that time to double, triple or more. By planning ahead and properly complying, you can expedite the loan closing process.
1) Business Entity - If you are a start-up and intend the Borrower to be a corporation or partnership, which you have not already formed, please do so before submitting the loan application. The expense is minimal compared to the cost of delays if you wait.
2) Holder of Contracts, Agreements & Leases - The Borrower must hold in its name all contracts (e.g., job contracts), agreements (e.g., franchise and/or license agreements), leases (e.g., for premises), etc., related to the business.
3) Insurance
a) Absolute Collateral Assignment of Life Insurance
If your loan is approved, there will be a mandatory requirement for the principal(s) of the borrower to provide absolute collateral assignment of life insurance, in an amount equal to the unpaid gross loan amount, at a minimum, for the full term of the loan. While the coverage is usually in the aggregate (i.e., to be allocated among the principals at their discretion), sometimes the SBA specifies the allocation. The SBA District Office to which the loan application is submitted has the ultimate authority regarding specific requirements. Factors impacting the decision include, but are not limited to, each principal's insurability, involvement in and relative significance to the business operations, relationship of principals, etc.
You should initiate obtaining the policy(ies) promptly. However, wait until you have received specific details in the SBA Loan Authorization to finalize the coverage and collateral assignment because the SBA may revise our proposed coverage by individual.
The absolute collateral assignment of life insurance should be made to:
The insurance policy may be term, including decreasing term (decreasing identical to the amortization schedule of the loan), or an existing whole life policy or other permanent type of insurance.
b) Hazard Insurance - Hazard insurance, naming_____________. as Loss Payee, is required on all real estate and personal property taken as collateral. At a minimum, collateral includes the tangible assets of the business. It can be obtained quickly, so wait until you receive specific instructions.
c) Title Insurance on Real Estate Used as Collateral - Title insurance, naming______________. as Loss Payee, may be required on real estate provided as collateral. To save expense, check with the title policy insurer for existing mortgage(s) to determine whether or not a rider can be attached to the existing title insurance policy to meet this requirement.
4) If you will be renting your business location:
a) Lease Terms & Conditions - In most situations, you do not need an executed lease when you apply for the loan, however, at a minimum, identify the general area of the business location and provide realistic estimated occupancy costs (i.e., rent, common area maintenance charges, etc.).
We will notify you if a copy of the proposed lease or a letter from the landlord outlining the proposed terms and conditions of the lease is needed.
b) Terms of Premise's Lease - Premise's lease, including renewal options, must at a minimum, equal the term of the loan, which for leased locations will probably be 1 0 years.
c) Lessor's Agreements - There is a range of requirements of the lessor (i.e., landlord), depending on the SBA office approving the loan. It is important to address them up-front with your leasing agent and the lessor, because if you sign the lease without obtaining the lessor's agreement to these issues in advance, the lessor may refuse to accept them later. If the requirements are not be able to be waived, you could find yourself with a lease but no loan. Issues include:
c1) Collateral Assignment of Lease - In essence, this provides the Lender, in the event of Borrowers default on the loan, with rights to access business assets used as collateral for the loan, to remove from and/or sell those assets on the leased premises, and to transfer and assign Borrower's rights to another party. Lender is responsible for rent during this time.
c2) Lessor Notice to Lender - In the event of a Borrower's default on its lease, Lessor agrees to give Lender up to 90 days' notice of intent to terminate the lease.
c3) Lessor's Subordination - Lessor agrees to subordinate any lien on the property of Borrower that is security for the loan to Lender's lien(s) and rights.
5) If your business is a franchisee/licensee:
Franchise/License Agreement(s) - These documents do not have to be signed before you apply for the loan; however, we need a copy of the license agreement (if a franchise, a copy of the franchisees UFOC), before we can submit your application to the SBA. The license/franchise agreement including renewal options, must, at a minimum, equal the term of the loan, which is usually at least 10 years.
This checklist has been provided to assist you in gathering the necessary information for the initial evaluation of your loan request. Complete information will be necessary to process your application. Forms are provided for items 1-12.
| |Loan Request Form (first 3 pages) |
| |History of Business Form (to be completed by all applicants) |
| |Management Resume Provide complete resumes on all individuals referred to in #2 above including key managers (copy form as needed). |
| |Personal Financial Statement Complete this form for: (1) each proprietor, or (2) each limited partner who owns 20% or more interest & each general |
| |partner, or (3) each stockholder owning 20% or more voting stock & each corporate officer and director, or (4) other person or entity providing a guaranty|
| |on the loan. |
| |Personal Income and Expense Analysis |
| |One Year Projection of Profit & Loss by Month (attach assumptions) |
| |Notes Payable Schedule The figures in Balance Due column of schedule should coincide with note Balances on the interim Business Financial Statement |
| |(please note: if not applicable write "None" then sign & date) |
| |Aging of Accounts Receivable and Accounts Payable Summary- Please attach actual schedules to summary. (Include for affiliate business as well.) |
| |Statement of Personal History (SBA form 912) |
| |Environmental Questionnaire (3 pages) |
| |Signed Authorization to Release information |
| |IRS form 4506 One each signed by all principals owning 20% or more and by borrowing entity(s). |
|IN ADDITION, PLEASE PROVIDE THE FOLLOWING: |
| |Business Plan- (start-up business) Include a description of management, feasibility analysis, assumptions, site evaluation, and demographics. |
| |Interim Profit & Loss, and Balance Sheet- Within 45 days old for business being: 1) acquired, 2) existing/expanded, and 3) affiliates (20% or more |
| |ownership interest by any of the owners/partners/shareholders of proposed borrower). |
| |Business Financial Statements and Tax Returns- Income statements, balance sheets, and tax returns for three prior year-end time periods for existing |
| |business & any affiliates. |
| |Historical Financial Information- Income Statement & Tax Returns for the past three years on any business being acquired. |
| |Copy of Proposed Purchase Agreement- For Real Estate |
| |Copy of Purchase Orders/invoices- For equipment, leasehold improvements, etc. |
| |Uniform Franchise Offering Circular- (*franchise business only) |
| |Copy of Proposed Franchise Agreement or Letter of Approval from Franchiser (*franchise business only) |
| |Personal Tax Returns Completed federal tax returns for the past three years on each individual referenced to in #4 above (or signed extension). |
| |Copy of Existing or Proposed Lease Agreement(s) |
| |If not a U.S. citizen, please attach proof of resident alien status Photocopy of both sides of "green card." |
| |Copy of Filed Certificate of Incorporation Along with articles of incorporation. |
| |Copies of Recent Title Reports On all properties taken as collateral. |
| |Site Analysis Include photos of property/business location (Refer to CCC Site Visit & Location Analysis Form 10/96). |
|APPLICANT COMPANY | |Contact Numbers |
|Legal Business Name: | |Phone: | |
|dba name (if applicable): | |Fax: | |
|Address: | |Cell: | |
|City: | |State | |Zip | |
|Primary Contact: | |Email: | |
|Type of Entity: | |Corporation |( |S-Corp | |C-Corp | |LLC) |
| | |Sole Proprietorship | |No. of Employees: |Existing: | |
| | |General Partnership | | | |After this Financing: | |
| | |Limited Partnership | | | |Affiliates: | |
|Date Established: | |Date Incorporated: | |State of Incorporation: | |
|Employer Tax I.D.: | |Name of Franchise (if applicable) | |
OWNERSHIP OF APPLICANT COMPANY
List below all owners, partners, and stockholders with 20% or more ownership interest
|Name | | |Name | |
|Title | | |Title | |
|Address | | |Address | |
|City, State, Zip | | |City, State, Zip | |
|Telephone | | |Telephone | |
|Percent of Ownership | | |Percent of Ownership | |
|Social Security #: | | |Social Security #: | |
|Name | | |Name | |
|Title | | |Title | |
|Address | | |Address | |
|City, State, Zip | | |City, State, Zip | |
|Telephone | | |Telephone | |
|Percent of Ownership | | |Percent of Ownership | |
|Social Security #: | | |Social Security #: | |
(If additional owners, please attach on separate sheet)
AFFILIATES
List below all business concerns in which the Applicant Company or any of the individuals listed in the Ownership section above have any ownership.
|Name | |Name | |
|Individual Name | |Individual Name | |
|Address | |Address | |
|City, State, Zip | |City, State, Zip | |
|Telephone | |Telephone | |
|Percent of Ownership | |Percent of Ownership | |
(If additional affiliates, please attach on separate sheet)
PROFESSIONAL ASSISTANCE
|Attorney's Name | |Accountant's Name | |
|Firm | |Firm | |
|Address | |Address | |
|City, State, Zip | |City, State, Zip | |
|Telephone | |Telephone | |
|Contact | |Contact | |
BANK REFERENCES (Business and Personal)
|Name | |Name | |
|Address | |Address | |
|City, State, Zip | |City, State, Zip | |
|Telephone | |Telephone | |
DESCRIPTION OF FINANCIAL ACCOUNTS (Required for company and each Guarantor)
Please include description and account numbers for ail liquid assets (mutual funds, IRA, money market accounts)
|Name of Institution |Type of Account |Account Number |Current Balance |Date Opened |
| | | | | |
| | | | | |
| | | | | |
INSURANCE COMPANY
Contact Telephone
ADDITIONAL CREDIT REFERENCES
|Supplier | |Supplier | |
|(For Franchise - Food supplier) | |(For Franchise - Food supplier) | |
|Address | |Address | |
|City, State, Zip | |City, State, Zip | |
|Telephone | |Telephone | |
|Contact | |Contact | |
OTHER MAJOR CREDITORS (Finance company, vendors, suppliers, etc.)
|Name | |Name | |
|Address | |Address | |
|City, State, Zip | |City, State, Zip | |
|Telephone | |Telephone | |
|Contact | |Contact | |
|Type of Credit | |Est. | |Type of Credit | |Est. | |
|Current Bal. | |Monthly Pmt. | |Current Bal. | |Monthly Pmt. | |
ESTIMATED PROJECT COSTS
|Land Acquisition |$ | |
|New Building Construction |$ | |
|Construction Contingency/Overruns |$ | |
|Land and Building Acquisition |$ | |
|Building Improvements/Repairs |$ | |
|Acquisition of Machinery/Equipment |$ | |
|Acquisition of Furniture/Fixtures |$ | |
|Inventory Purchase |$ | |
|Working Capital (including Accounts Payable) |$ | |
|Acquisition of all or part of Existing Business |$ | |
|Payoff Bank Loan |$ | |
|Other Debt Payment |$ | |
|Estimated Closing Costs: | | |
|Construction Loan Fee (estimated) |$ | |
|Construction Loan Interest (estimated) |$ | |
|Survey Fee (estimated) |$ | |
|Title Insurance (estimated) |$ | |
|Appraisal Fee (estimated) |$ | |
|Legal Fees (estimated) |$ | |
|Other ( ) |$ | |
|Deposits ( ) |$ | |
|Franchise Fee |$ | |
|SBA Guarantee Fee |$ | |
|Other Fees/Costs( ) |$ | |
|TOTAL ESTIMATED PROJECT AMOUNT |$ |0[pic]0 |
|LESS OWN CASH/EQUITY TO BE INJECTED |$ | |
|TOTAL LOAN REQUESTED FOR PROJECT |$ |0[pic]0 |
*Totals will automatically calculate when you print if “Update Fields” is selected in Word (“Tools”, “Options”, “Print Tab”, “Update Fields)
|COMMENTS & EXPLANATIONS: |
| |
|HISTORY OF BUSINESS |
|(Use separate attachments to answer questions if necessary) |
|BACKGROUND AND HISTORY OF PRINCIPALS AND COMPANY |
| |
|NATURE OF BUSINESS, TYPES OF PRODUCTS & SERVICE |
| |
|CUSTOMER PROFILE |
| |
|Major customers |primary competitors |
| | |
|MAJOR PAST ACCOMPLISHMENTS |
| |
FUTURE EXPANSION
Does your company currently have plans for future expansion?
Number of locations?____ ___ Over what period of time?
How many new company locations are planned for this market?
|HOW WILL THIS LOAN BENEFIT YOUR COMPANY? |
| |
|WILL THE FUNDING OF THIS LOAN CREATE NEW EMPLOYMENT OPPORTUNITIES? |
| |
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|U.S. SMALL BUSINESS ADMINISTRATION | | | | | | | |As of , |
|Complete this form for: (1) each proprietor, or (2) each limited partner who owns 20% or more interest and each general partner, or (3) each stockholder owning |
|20% or more of voting stock, or (4) any Person or entity providing a guaranty on the loan. |
|Name |Business Phone |
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|City, State, & Zip Code |
|Business Name of Applicant/Borrower |
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| | | | | |selected in Word (“Tools”, “Options”, “Print Tab”, “Update Fields) |
|Section 1. Source of Income | | | | |C| | | | | |
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|Other Income (Describe below)* |$ | | | |O| | | |$ | |
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|Description of Other Income in Section 1. |
| | | | | | | | | | |
|*Alimony or child support payments need not be disclosed in "Other Income" unless it is desired to have such payments counted toward total income. |
| |(Use attachments if necessary. Each attachment must be identified as a part of |
| |this statement and signed.) |
|Name and Address of Noteholder(s) |Original |C| |Payment |Frequency |H| |
| |Balance |u| |Amount |(monthly, etc.) |o| |
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|Section 3. |
|Number of Shares |Name of Securities |Cost |Market Value |Date of |Total Value |
| | | |Quotation/Exchange |Quotation/Exchange | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
|Section 4. |(List each parcel separately. Use attachment if necessary. |
| |Each attachment must be identified as a part of this statement and signed.) |
| |Property A |Property B |Property C |
|Type of Property | | | |
|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 | | | |
|Section 5. |(Describe, and if any is pledged as security, state name and address of lien holder, amount of|
| |lien, terms of payment and if delinquent, describe delinquency) |
| |
|Section 6, Unpaid Taxes. (Describe in detail, as to type, to whom payable, when due, amount, and to what property, if any, a tax lien attaches.) |
| |
|Section 7. Other Liabilities. (Describe in detail.) |
| |
|Section S. Life Insurance Held. (Give face amount and rash surrender value of policies - name of insurance company and beneficiaries) |
| |
|I authorize SBA/Lender to make inquiries as necessary to verify the accuracy of the statements made and to determine my creditworthiness. I certify the above and |
|the statements contained in the attachments are true and accurate as of the stated date(s). These statements are made for the purpose of either obtaining a loan |
|or guaranteeing a loan. I understand FALSE statements may result in forfeiture of benefits and possible prosecution by the U.S. Attorney General (Reference 18 |
|U.S.C. 1001). |
|Signature: | |Date: | |Social Security Number: | |
|Signature: | |Date: | |Social Security Number: | |
|PLEASE NOTE: The estimated average burden hours for the completion of this form is 1.5 hours per response. If you have questions or comments concerning this |
|estimate or any other aspect of this information, please contact Chief, Administrative Branch, U.S. Small Business Administration, Washington, D.C. 20416, and |
|Clearance Officer, Paper Reduction Project (3245-0188), Office of Management and Budget Washington, D.C. 20503. |
|MANAGEMENT RESUME |
|Please fill in all spaces. If an item is not applicable, please indicate as such. |
|You may include additional relevant information on a separate exhibit. SIGN/DATE where indicated. |
|PERSONAL INFORMATION | |
|NAME | |SS# | |
|DATE OF BIRTH | |PLACE OF BIRTH | |
|RESIDENCE TELEPHONE | |BUSINESS TELEPHONE | |
|RESIDENCE ADDRESS | | |FROM: | |TO: | |
|PREVIOUS ADDRESS | | |FROM: | |TO: | |
|SPOUSE’S NAME | | |SS#: | |
|ARE YOU EMPLOYED BY THE U.ERNMENT? | Yes No |AGENCY/POSITION | |
|ARE YOU A U.S.CITIZEN? Yes No IF NO, GIVE ALIEN REGISTRATION NUMBER |
| | | | |
|EDUCATION: | | | |
|College Technical Training-Name/ Location |Dates Attended |Major |Degree/ Certificate |
| | to | | |
| | to | | |
| | to | | |
|MILITARY SERVICE BACKGROUND: | | | |
|Branch of Service | |Dates of Service | |
|WORK EXPERIENCE: List chronologically beginning with present employment. | |
|Company Name | |
|Address | |
|From | |To | |Title/Position | |
|Duties | |
| | |
|Company Name | |
|Address | |
|From | |To | |Title/Position | |
|Duties | |
| | |
|Company Name | |
|Address | |
|From | |To | |Title/Position | |
|Duties | |
| | |
| | |
|Signature |Date |
PERSONAL INCOME AND EXPENSE ANALYSIS
|NAME | |
|INCOMES: |MONTHLY |ANNUALLY |
|AVAILABLE DRAW (NP + DEPRECIATION) | | | |
|GROSS SALARY (PRINCIPAL) | | | |
|GROSS SALARY (SPOUSE) ---------- | | | |
|RENTAL INCOME (GROSS) | | | |
|INTEREST INCOME (RECURRING) | | | |
|ALIMONY | | | |
|OTHER INCOME (RECURRING) | | | |
|TOTAL INCOME | | | |
| | | | |
|EXPENSES: | | | |
|RESIDENCE EXPENSE (RENT or P&I) | | | |
|RENTAL MORTGAGES (P&I) | | | |
|RENTAL EXPENSES (CASH EXP. less P&I) | | | |
|AUTO LOANS (ALL) | | | |
|INSTALLMENT LOANS (ALL) | | | |
|REVOLVING CREDIT (5% of TRW BALANCES) | | | |
|UTILITIES/PHONE (ESTIMATE) | | | |
|INSURANCES (ALL PERSONAL) | | | |
|FOOD (ESTIMATE) | | | |
|CLOTHING (ESTIMATE) | | | |
|MEDICAL EXPENSES (3 YR. AVERAGE) | | | |
|INCOME TAXES (HISTORICAL RATE) | | | |
|PROPERTY TAXES (HISTORICAL RATE) | | | |
|ALIMONY (IF APPLICABLE) | | | |
|CHILD CARE (IF APPLICABLE) | | | |
|OTHER EXPENSES | | | |
|MISCELLANEOUS | | | |
|(Typical range is 5% - 10% of total income) | | | |
| | | | |
|TOTAL EXPENSES | | | |
| | | | |
|NET DISCRETIONARY INCOME | | | |
|COVERAGE RATIO (INCOME/EXPENSE) | | | |
| | | | |
| | | | |
|Signature | |Date | |
PROFIT & LOSS PROJECTION
COMPANY:
|MONTH |1 |
|Name and Address of Applicant (Firm Name)(Street, City, State, and ZIP Code) |SBA District/Disaster Area Office |
| | |
| |Amount Applied for (when applicable) |File No. (if known) |
| | | |
|1. Personal Statement of: (State name in full, if no middle name, state (NMN), or if|Name and Address of participating lender or surety co. (when applicable |
|initial only, indicate initial.) List all former names used, and dates each name was|and known) |
|used. | |
|Use separate sheet if necessary. | |
| First Middle Last | |
| |2. Date of Birth (Month, day, and year) |
| | |
| |3. Place of Birth: (City & State or Foreign Country) |
|4. Give the percentage of ownership or stock |Social Security No. | |
|owned or to be owned in the small business | | |
|concern or the Development Company | | |
| | |U.S. Citizen? YES NO |
| | |If no, give alien registration number: |
|5. Present residence address: | Most recent prior address (omit if over 10 years ago): |
| From: | From: |
| To: | To: |
| Address: | Address: |
| Home Telephone No. (Include A/C): | |
| Business Telephone No. (Include A/C): | |
|IT IS AGAINST SBA's POLICY TO PROVIDE ASSISTANCE TO PERSONS NOT OF GOOD CHARACTER; THEREFORE, CONSIDERATION IS GIVEN TO A PERSON'S BEHAVIOR, INTEGRITY, CANDOR,|
|AND DISPOSITION TOWARD CRIMINAL ACTIONS. IT IS ALSO AGAINST SBA's POLICY TO PROVIDE ASSISTANCE NOT IN THE BEST INTEREST OF THE UNITED STATES; FOR EXAMPLE, IF |
|THERE IS REASON TO BELIEVE THE EFFECT OF SUCH ASSISTANCE WILL BE TO ENCOURAGE OR SUPPORT, DIRECTLY OR INDIRECTLY, ACTIVITIES HARMFUL TO THE SECURITY OF THE |
|UNITED STATES. |
| |
|THEREFORE, IT IS IMPORTANT THAT THE NEXT THREE QUESTIONS BE ANSWERED TRUTHFULLY AND COMPLETELY. AN ARREST OR CONVICTION RECORD WILL NOT NECESSARILY DISQUALIFY |
|YOU; HOWEVER, AN UNTRUTHFUL ANSWER WILL CAUSE YOUR APPLICATION TO BE DENIED. |
| |
|IF YOU ANSWER "YES" TO 6, 7, OR 8, FURNISH DETAILS IN A SEPARATE EXHIBIT. INCLUDE DATES, LOCATION, FINES, SENTENCES, WHETHER MISDEMEANOR OR FELONY, DATES OF |
|PAROLE/PROBATION, UNPAID FINES OR PENALTIES, NAME(S) UNDERWHICH CHARGED, AND ANY OTHER PERTINENT INFORMATION. |
|6. Are you presently under indictment, on parole or probation? |
| Yes No (If yes, indicate date parole or probation is to expire.) |
|7. Have you ever been charged with and or arrested for any criminal offense other than a minor motor vehicle violation? Include offenses which have been |
|dismissed, discharged, or not prosecuted (All arrests and charges must be disclosed and explained on an attached sheet.) |
| Yes No |
|8. Have you ever been convicted, placed on pretrial diversion, or placed on any form of probation, including adjudication withheld pending probation, for any |
|criminal offense other than a minor vehicle violation? |
| Yes No |
|9. I authorize the Small Business Administration Office of Inspector General to request criminal record information about me from criminal justice agencies for|
|the purpose of determining my eligibility for programs authorized by the Small Business Act, as amended. |
| |
|CAUTION: Knowingly making a false statement on this form is a violation of Federal law and could result in criminal prosecution, significant civil penalties, |
|and a denial of your loan, surety bond, or other program participation. A false statement is punishable under 18 USC 1001 by imprisonment of not more than five|
|years and/or a fine of not more than $10,000; under 15 USC 645 by imprisonment of not more than two years and/or a fine of not more than $5,000; and, if |
|submitted to A Federally insured institution, under 18 USC 1014 by imprisonment of not more than twenty years and/or a fine of not more than $1,000,000. |
|Signature |Title |Date |
|Agency Use Only | |
|10 Fingerprints Waived | | |11 Cleared Processing | | |
| |Date Approving Authority | | |Date Approving Authority | |
| Fingerprints Required | | | Request a Character Evaluation | | |
| Date Sent to OIG _________ |Date Approving Authority | | |Date Approving Authority | |
SBA 912 (5-97) SOP 5010.4 Previous Edition Obsolete
AGING OF ACCOUNTS RECEIVABLE AND ACCOUNTS PAYABLE SUMMARY
(Please attach actual schedules to support summary information)
Company Name:
NOTE: Accounts Receivable And Accounts Payable must reconcile with the current business balance sheet that is provided with the application.
|AGING |Accounts Receivable | |Accounts Payable |
|UNDER 30 DAYS |$ | |$ |
|30- 59 DAYS |$ | |$ |
|60- 89 DAYS |$ | |$ |
|90- 119 DAYS |$ | |$ |
|120- 180 DAYS |$ | |$ |
|OTHER |$ | |$ |
|TOTALS: |$ | |$ |
|A/R Concentration greater than or equal to 10% of total |$ |
|A/R Percentage % greater than or equal to 90 days |$ |
|A/P Concentration greater than or equal to 10% of total |$ |
|A/P Percentage % greater than or equal to 90 days |$ |
IDENTIFY CONCENTRATIONS GREATER THAN 15%
| |
EXPLAIN COLLECTION/ PAYMENT PROCESS
| |
|Signature | |Date | |
This form is to be completed by the Applicant and returned to the Lender prior to submission of the application to SBA. The applicant may wish to retain an engineer and/or attorney to assist in the completion of this questionnaire.
|1. GENERAL INFORMATION | | |
|A. Business Address | |
| Brief Legal Description | |
| |
| |
| |
|B. Name of current property owner(s): | |
| | | |
|C. Type of business currently operating the premises. SIC code if known |
| | |
| |1. Personal Services |
| |2. Manufacturing |
| |3. Transportation |
| |4. Retail Service |
| |5. Health Service |
| |6. Education Service |
| |7. Engineering & Management |
| |8. Other |
| | |
|D. Type of business to be operated on the premises. SIC code if known |
| | |
| |1. Personal Services |
| |2. Manufacturing |
| |3. Transportation |
| |4. Retail Service |
| |5. Health Service |
| |6. Education Service |
| |7. Engineering & Management |
| |8. Other |
| | |
|E. Historic use of the property. (Check as many as apply) SIC Code if known |
| | |
| |1. Personal Services |
| |2. Manufacturing |
| |3. Transportation |
| |4. Retail Service |
| |5. Health Service |
| |6. Education Service |
| |7. Engineering & Management |
| |8. Other |
| |
|F. Did this property have, or will have, underground storage tanks in use? |
| |
| |Yes |
| |No |
| |Unknown as to past use |
| | |
|G. Environmental Permits |
| | |
| |Current ownership has current permits |
| |Type of permit(s): | |
| | |
| |Current owner/ tenant had permits |
| |Reason for no longer having permit(s): | |
| | |
| |Current owner / Tenant has applied for permit(s) |
| |Types of Permit(s): | |
| | |
| | |
|H. Is the owner/tenant aware of any notices of violations, or correspondence with governmental agencies, or internal correspondence regarding |
|the release, threat of release, or cleanup of hazardous substances at this property? |
| |Yes |
| |No |
| |Unknown |
| | |
|I. Type of business(es) currently operating on property adjacent to applicant business. |
|(Check as many as apply) SIC codes if known: |
| |1. Personal Services |
| |2. Manufacturing |
| |3. Transportation |
| |4. Retail Service |
| |5. Health Service |
| |6. Education Service |
| |7. Engineering & Management |
| |8. Other |
| | |
|J. Has an environmental audit of this property ever been conducted? |
| | |
| |Yes |
| |Date | |By Whom: | |
| |No |
| |Unknown |
| | |
|INFORMATION REGARDING HAZARDOUS SUBSTANCES |
|Please provide snapshots of the property. |
|A. Are there currently chemicals, fuels, pesticides or waste products on this property.? (Check as many as apply). |
| |Yes |
| | |Stored in Tanks |
| | | |
| | |Stored in Drums |
| | |Disposed of directly on the property or adjacent sites |
| | |Stored or disposed of in surface impoundment's, pit, landfills, ponds, lagoons or piles. |
| |No |
| | |
|B. Is there now or has there ever been any system of underground disposal (e.g. septic tanks) at this property? |
| |Yes |
| | |Septic Tank |
| | |Other (Explain) |
| |No |
| | |
|C. If you answered "Yes" to having chemicals, etc., currently on the property, have there been any accidental spills? |
| |Yes |
| |If yes, what was the name(s) of the chemical(s), etc., which spilled? |
| | |
| | |
| |No |
| |Unknown as to past usage |
| | |
|D. If you answered "Yes" to having chemicals, etc., currently on the property, what is the current practice for disposal of the used solvents, |
|oils, metal shavings, plating solutions, etc.? |
| |
| |
|Signature |Date |
| | |
AUTHORIZATION TO RELEASE INFORMATION
I/we hereby authorize PetroMAC Inc. or any of its affiliates to make all inquiries it deems necessary to verify the accuracy of the information provided herein, and to determine my/our creditworthiness.
I/we also hereby authorize the release of any information necessary for any purpose related to our credit transaction with PetroMAC Inc..
I/we hereby certify that the enclosed application information including attachments/exhibits are valid and correct to the best of my/our knowledge.
All proprietors, partners, directors, officers, and stockholders with 20% or more ownership interest must sign this form (spouses should sign when applicable).
| | | | | | | |
|Company | |Signature | |Title | |Date |
| | | | | | | |
|Company | |Signature | |Title | |Date |
| | | | | | | |
|Company | |Signature | |Title | |Date |
| | | | | | | |
|Company | |Signature | |Title | |Date |
| | | | | | | |
|Company | |Signature | |Title | |Date |
| | | | | | | |
|Company | |Signature | |Title | |Date |
| | | | | | | |
|Company | |Signature | |Title | |Date |
| | | | | | | |
|Company | |Signature | |Title | |Date |
| |[pic] | |
|Form 4506 |U.S. Small Business Administration |OMB No. 1545-0429 |
|(Rev. May 1997) |Request for Copy or Transcript of Tax Form | |
|Department of the |Read Instructions before completing this form. | |
|Treasury |Type or print clearly. Request may be rejected if the form is incomplete or illegible. | |
|Internal Revenue Service | | |
|Note: Do not use this form to get tax account information. Instead, see instructions below. |
|1a Name shown on tax form. If a joint return, enter the name shown first. |1b First social security number on tax form or employer |
| |identification number (See Instructions.) |
| | |
|2a If a joint return, spouse's name shown on tax form |2b Second social security number on tax form |
| | | | |
|3 Current name, address (including apt., room, or suite no.), city, state, and ZIP code |
| |
|4 Address, (including apt, room, or suite no.), city, state, and ZIP code shown on the last return filed if different from line 3. |
| |
|5 If copy of form or a tax return transcript is to be mailed to someone else, enter the third party’s name and address. |
| |
|6 If we cannot find a record of your tax form and you want the payment refunded to the third party, check here |
|7 If name in third party's records differs from line Ia above, enter that name here (see instructions) |
|8 Check only one box to show what you want. There is no charge for items 8a, b, and c: |
| Tax return transcript of Form 1040 series filed during the current calendar year and the 3 prior calendar years. (see instructions). |
|Verification of nonfiling. |
|Form(s) W-2 information (me Instructions). |
|Copy of tax form and all attachments (including Form(s) W-2, schedules, or other forms). The charge Is $23 for each period requested. |
|Note: If these copies must be certified for court or administrative proceedings, see instructions and check here |
|9 If this request is to meet a requirement of one of the following, check all boxes that apply. |
| Small Business Administration | Department of Education | Department of Veterans Affairs | Financial Institution |
|10 Tax form number (Form 1040, 1040A, 941, etc.) |12 Complete only if line 8d is checked. |Does not apply |
| |Amount due: |to SBA transcript |
| |a Cost for each period |requests |
|11 Tax period(s) (year or period ended date). If more than four, see | b Number of tax periods requested on line 11 | |
|instructions. |c Total cost. Multiply line 12a by line 12b |$ |
| | | | |Full payment must accompany your request Make check or |
| | | | |money order payable to “Internal Revenue Service” |
|Caution: Before signing, make sure all items are complete and the form is dated |
| |
|I declare that I am either the taxpayer whose name is shown on line 1a or 2a or a person authorized to obtain the tax information requested. I am aware|
|that based upon this form, the IRS will release the tax information requested to any party shown on line 5. The IRS has no control over what that party|
|does with the information. |
| | | |Telephone number of requester |
| | | | |
|Please |Signature. See instructions. It other than taxpayer, attach authorization |Date |Best time to call |
| |document. | | |
|Sign | | | |
|Here |Title (If line 1a above is a corporation, partnership, estate, or trust) | |TRY A TAX RETURN TRANSCRIPT |
| | | |(see line 8a instructions) |
| |Spouse’s signature |Date | |
| | | | |
Instructions
Section references are to the Internal
Revenue code.
TIP: If you had your tax form filled in by a paid preparer, check first to see if you can get a copy from the preparer. This may save you both time and money.
Purpose of Form. ---Use Form 4506 to get a tax return transcript, verification that you did not file a Federal tax return, Form W-2, information, or a copy of a tax form. Allow 6 weeks after you file a tax form before you request a copy of it or a transcript. For W-2 information, wait 13 months after the end of the year in which the wages were earned. For example, wait until Feb. 1999 to request W-2 information for wages earned in 1997.
Do not use this form to request Forms 1099 or tax account information. See this page for details on how to got these items.
Note: Form 4506 must be received by the IRS within 60 calendar days after the date you signed and dated the request.
How Long Will It Take? ---You can get a tax return transcript or verification of nonfiling within 7 to 10 workdays after the IRS receives your request. It can take up to 60 calendar
days to get a copy of a tax form or W-2 information. To avoid any delay, be sure to furnish all the information asked for on Form 4506.
Forms 1099.---If you need a copy of a Form 1099, contact the payer. If Me payer cannot help you, call or visit the IRS to get Form 1099 Information.
Tax Account Information ---If you need a statement of your tax account showing any later changes that you or the IRS made to the original return, request tax account information. Tax account information lists
(continued on back)
certain items from your return, including any later changes.
To request tax account information, write or visit an IRS office or call the IRS at the number listed in your telephone directory.
If you want your tax account information sent to a third party, complete Form 8821, Tax Information authorization. You may get this form by phone (call 1-800-829-3676) or on the Internet (at ).
Line 1b --- Enter your employer identification number (EIN) only if you are requesting a copy of a business tax form. Otherwise, enter the first social security number (SSN) shown on the tax form.
Line 2b --- If requesting a copy or transcript of a joint tax form, enter the second SSN shown on the tax form.
Note: If you do not complete line 1b and, if applicable, line 2b, there may be a delay in processing your request
Line 5 --- If you want someone else to receive the tax form or tax return transcript (such as a CPA, an enrolled agent, a scholarship board, or a mortgage lender), enter the name and address of the individual. If we cannot find a record of your tax form, we will notify the third party directly that we cannot fill the request.
Line 7 --- Enter the name of the client, student, or applicant if it is different from the name shown on line 1 a. For example, the name on line 1 a may be the parent of a student applying for financial aid. In this case, you would enter the student's name on line 7 so the scholarship board can associate the tax form or tax return transcript with their file.
Line 8a --- If want a tax return transcript, check this box. Also, on line 10 enter the tax form number and on line 11 enter the tax period, for which you want the transcript.
A tax return transcript is available for any returns of the 1040 series (Form 1040, Form 1040A, 1040EZ, etc.). It shows most line items from the original return, including accompanying forms and schedules. In many cases, a transcript will meet the requirement of any lending institution such as a financial institution, the Department of Education, or the Small Business Administration. It may also be used to verify that you did not claim any itemized deductions for a residence.
Note: A tax return transcript does not reflect any changes you or the IRS made to the original return. If you want a statement of your tax account with the changes, see Tax Account Information on page 1.
Line 8b --- Check this box only if you want proof from the IRS that you did not file a return for the year. Also, on line 11 enter the tax period for which you want verification of nonfiling.
Line 8c --- If you want only Form(s) W-2 information, check this box. Also, on line 10 enter "Forms(s) W-2 only" and on line 11 enter the tax period for which you want the information.
You may receive a copy of your actual Form W-2 or a transcript of the information, depending on how your employer filed the form. However, state withholding information is not shown on a transcript. If you have filed your tax return for the year the wages were earned, you can get a copy of the actual Form W-2 by requesting a complete copy of your return and paying the required fee.
Contact your employer if you have lost your current years Form W-2 or have not received it by the time you are ready to prepare your tax return.
Note: If you are requesting information about your spouse's Form W-2, your spouse must sign Form 4506.
Line 8d --- If you want a certified copy of a tax form for court or administrative proceedings, check the box to the right of line 8d. It will take at least 60 days to process your request.
Line 11 --- Enter the year(s) of the tax form or tax return transcript you want. For fiscal-year filers or requests for quarterly tax forms, enter the date the period ended; for example, 3/31/96, 6/30196, etc. If you need more than four different tax periods, use additional Forms 4506. Tax forms filed 6 or more years ago may not be available for making copies. However, tax account information is generally still available for these periods.
Line 12c --- Write your SSN or EIN and "Form 4506 Request" on your check or money order. If we cannot fill your request, we will refund your payment.
Signature --- Requests for copies of tax forms or tax return transcripts to be sent to a third party must be signed by the person whose name is shown on line I a or by a person authorized to receive the requested information.
Copies of tax forms or tax return transcripts for a jointly filed return may be furnished to either the husband or the wife. Only one signature is required. However, see the line 8c instructions. Sign Form 4506 exactly as your name appeared on the original tax form. If you changed your name, also sign your current name.
For a corporation, the signature of the president of the corporation, or any principal officer and the secretary, or the principal officer and another officer are generally required. For more details on who may obtain tax information on corporations, partnerships, estates, and trusts, see section 6103.
If you are not the taxpayer shown on line I a, you must attach your authorization to receive a copy of the requested tax form or tax return transcript. You may attach a copy of the authorization document if the original has already been filed with the IRS. This will generally be a power of attorney (Form 2848), or other authorization, such as Form 8821, or evidence of entitlement (for Title 11 Bankruptcy or Receivership Proceedings). If the taxpayer is deceased, you must send Letters Testamentary or other evidence to establish that you are authorized to act for the taxpayer's estate.
Where To File --- Mail Form 4506 with the correct total payment attached, if required, to the Internal Revenue Service Center for the place where you lived when the requested tax form was filed.
Note: You must use a separate form for each
Service center from which you are requesting a copy of your tax form or tax return
If you lived in: Use this address:
|New Jersey, New York | |1040 Waverly Ave. |
|(New York City and | |Photocopy Unit |
|counties of Nassau, | |Stop 532 |
|Rockland, Suffolk, and | |Holtsville, NY 11742 |
|Westchester) | | |
|New York (all other | |310 Lowell St. |
|counties), Connecticut, | |Photocopy Unit |
|Maine, Massachusetts, | |Stop 679 |
|New Hampshire, | |Andover, MA 0 1810 |
|Rhode Island, Vermont | | |
|Florida, Georgia, | |4800 Buford Hwy. |
|4800 Buford Hwy. | |Photocopy Unit |
|South Carolina | |Stop 91 |
|Photocopy Unit | |Doraville, GA 30362 |
| | | |
| | | |
| | | |
| | | |
| | | |
|Indiana, Kentucky, | |P.O. Box 145500 |
|Michigan, Ohio, | |Photocopy Unit |
|West Virginia | |Stop 524 |
| | |Cincinnati, OH 45250 |
| | | |
| | | |
| | | |
| | | |
|Kansas, New Mexico, | |3651 South |
|Oklahoma, Texas | |Interregional Hwy. |
| | |Photocopy Unit |
| | |Stop 6716 |
| | |Austin, TX 73301 |
|Alaska, Arizona, | |P.O. Box 9941 |
|California (counties of | |Photocopy Unit |
|Alpine, Amador, Butte, | |Stop 6734 |
|Calaveras, Colusa, | |Ogden, UT 84409 |
|Contra Costa, Del Norte,| | |
|El Dorado, Glenn, | | |
|Humboldt, Lake, Lassen, | | |
|Marin, Mendocino, Modoc,| | |
|Napa, Nevada, Placer, | | |
|Plumes, Sacramento, San | | |
|Joaquin Shasta, Sierra, | | |
|Siskiyou, Solano, | | |
|Sonoma, Sutter, Tehama, | | |
|Trinity, Yolo, and | | |
|Yuba), Colorado, Idaho, | | |
|Montana, Nebraska, | | |
|Nevada, North Dakota, | | |
|Oregon, South Dakota, | | |
|Utah, Washington. | | |
|Wyoming California (all | | |
|other counties), Hawaii | | |
|California (all other | |5045 E. Butler Avenue |
|counties), Hawaii | |Photocopy Unit |
| | |Stop 52180 |
| | |Fresno, CA 93888 |
|Illinois, Iowa, | |2306 E. Bannister Road |
|Minnesota, | |Photocopy Unit |
|Missouri, Wisconsin | |Stop 57A |
| | |Kansas City, MO 64999 |
|Alabama, Arkansas, | |P.O. Box 30309 |
|Louisiana, Mississippi, | |Photocopy Unit |
|North Carolina, | |Stop 46 |
|Tennessee Delaware, | |Memphis, TN 38130 |
|District of Columbia, | | |
|Maryland, Pennsylvania, | | |
|Virginia, a foreign | | |
|country, or A. P.O. or | | |
|F.P.0 address | | |
|Delaware, | |11601 Roosevelt Blvd. |
|District of Columbia, | |Photocopy Unit |
|Maryland, Pennsylvania, | |DP 536 |
|Virginia, a foreign | |Philadelphia, PA 19255 |
|country, or A.P.O. or | | |
|F.P.O. address | | |
Privacy Act and Paperwork Reduction Act Notice. -- We ask for the information on this form to establish your right to gain access to your tax form or transcript under the Internal Revenue Code, including sections 6103 and 6109. We need it to gain access to your tax form or transcript in our files and properly respond to your request. If you do not furnish the information, we will not be able to fill your request. We may give the information to the Department of Justice or other appropriate law enforcement official, as provided by law.
You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by section 6103.
The time needed to complete and file this form will vary depending on individual circumstances. The estimated average time is: Recordkeeping, 13 min.; Learning about the law or the form, 7 min.; Preparing the form, 26 min.; and Copying, assembling, and sending the form to the IRS, 17 min.
If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler, we would be happy to hear from you. You can write to the Tax Forms Committee, Western Area Distribution Center, Rancho Cordova, CA 95743-0001. DO NOT send the form to this address. Instead, see Where To File on this page.
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