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South Central Kansas Economic Development District 9730 East 50th Street North, Bel Aire, KS 67226Phone: (316) 262-7035Fax: (316) 262-7062SCKEDD Business Loan ApplicationThank you for providing SCKEDD the opportunity to finance your business loan request. A completed and signed business loan application will help SCKEDD swiftly process your loan request. Please review page 3 ‘About Your Business’ to identify additional business and personal information required to complete the loan submission process. SCKEDD will evaluate the completed and signed business loan application, assess the eligibility and credit quality of the business and personal information, and then submit for loan decision. Please contact SCKEDD at (316) 262-7035 with any questions about this application or to learn more about how SCKEDD can help businesses meet their financing needs.APPLICANT COMPANYBusiness Name?Business EmailBusiness Website?Business Phone #Business Address City, State?Zip?Date Established?Federal Tax ID?DUNS #?Contact Name/Title?Contact Phone # ?Franchise Name (if applicable) How were you referred to SCKEDD??Type of Entity: FORMCHECKBOX Corporation “S” or “C” FORMCHECKBOX Limited Partnership(check one) FORMCHECKBOX Sole Proprietorship (d/b/a) FORMCHECKBOX General Partnership FORMCHECKBOX LLC (# of members): ______ FORMCHECKBOX Other: ____________ OWNERSHIP OF APPLICANT COMPANYList below all owners, partners, and stockholders with 20% or more ownership interest in the business. Attach a separate sheet if necessary. FORMCHECKBOX Provide copy of driver’s license (front & back) for each owner.Name?Name?Title?Title?Address?Address?City, State, Zip?City, State, Zip?Telephone?Telephone?Cell Phone?Cell Phone?E-Mail?E-Mail?% Ownership?% Ownership?SSN or Tax ID#?SSN or Tax ID#?Name?Name?Title?Title?Address?Address?City, State, Zip?City, State, Zip?Telephone?Telephone?Cell Phone?Cell Phone?E-Mail?E-Mail?% Ownership?% Ownership?SSN or Tax ID#?SSN or Tax ID#?AFFILIATESDoes the applicant company or any of the individuals listed in the Ownership Section have any ownership in other companies? FORMCHECKBOX Yes FORMCHECKBOX No If yes, please provide the following: FORMCHECKBOX Provide a list of all affiliate businesses. FORMCHECKBOX Provide business tax returns with all schedules for the past three (3) years for all affiliate businesses.ESTIMATED PROJECT COSTS BORROWER INJECTIONLand Purchase$Provide the source and amount ofNew Building Construction$injection into the project:Purchase Existing Land & Building$Building Improvements / Repairs$Personal Cash$Purchase Machinery / Equipment$Business Cash$Purchase Furniture / Fixtures$Other (specify) :$Purchase Inventory$?$Working Capital (including Accounts Payable)$?$Acquisition of an Existing Business (all or part)$Payoff Bank Loan, if eligible$Total Injection$Total Estimated Project Costs$Less Total Injection$Total Loan Requested for Project $PROJECT COST DOCUMENTATIONPlease provide the following project cost documentation, as applicable. FORMCHECKBOX Purchase Agreement (proposed or final) FORMCHECKBOX Furniture and/or fixtures bids FORMCHECKBOX Real Estate Purchase Agreement FORMCHECKBOX Machinery and/or equipment bids FORMCHECKBOX Contractor Bids FORMCHECKBOX Other: __________________________ABOUT YOUR BUSINESSStart-Up Business FORMCHECKBOX Complete History and Description of Business located on our website. If you already have a business plan, it can be provided in place of this information. Feel free to provide any additional information which you feel is important in describing your business. FORMCHECKBOX Provide Cash Flow Projections for first 12 months. FORMCHECKBOX Provide complete personal tax returns with all schedules for the past three (3) years for all owners with 20% or more ownership interest in the business.Existing Business FORMCHECKBOX Complete History and Description of Business located on our website. If you already have a business plan, it can be provided in place of this information. Feel free to provide any additional information which you feel is important in describing your business. FORMCHECKBOX Provide Cash Flow Projections for first 12 months. FORMCHECKBOX Provide current year-to-date financial statements for the business. (Balance Sheet and Income Statement) FORMCHECKBOX Provide complete business tax returns with all schedules for the past three (3) years. FORMCHECKBOX Provide complete personal tax returns with all schedules for the past three (3) years for all owners, with 20% or more ownership interest in the businessSCHEDULE OF COLLATERALList all collateral to be used as security for this loan. SECTION I - REAL ESTATELIST PARCELS OF REAL ESTATEAddressYear AcquiredOriginal CostMarket ValueAmount of LienName of LienholderGive a brief description of the improvements, such as size, type of construction, number of stories, and present condition (use additional sheet if more space is required.)SCHEDULE OF COLLATERAL (continued)SECTION II - PERSONAL PROPERTY OF BUSINESSList all equipment, fixtures, furnishing, or other personal property offers as collateral. Use “*” in Description to indicate a Business Asset. All items listed herein must show manufacturer or make, model, year, and serial number. Items with no serial number must be clearly identified (use additional sheet if more space is required.)Description-Show Manufacturer, Model, Serial No.YearAcquiredOriginal CostMarketValueCurrent LienBalanceName ofLienholderOwner and Key Management InformationRequired for all key management staff involved in day-to-day operations and all persons with ownership. FORMCHECKBOX Ownership ______% FORMCHECKBOX Key Management Staff Legal Name _____________________________________________________ Date of Birth ____________ SS# __________________ First Full Middle Name Maiden LastCurrent Home Address ______________________________________________ City ________________ State ____ Zip __________Dates at this Address: From: _____________________ to _____________________ Previous Home Address ______________________________________________ City ________________ State ____ Zip __________Dates at this Address: From: _____________________ to _____________________ Gender _________ Citizenship Status ______________ Birth City ___________ Birth State ____________ Birth County __________Race ___________________ Ethnicity: FORMCHECKBOX Hispanic/Latino FORMCHECKBOX Not Hispanic/Latino Veteran FORMCHECKBOX Yes FORMCHECKBOX No Branch ___________________ Discharge Type _________________ Rank at Discharge ______________Dates in the Military: From: _____________________ to _____________________ Spouse Name ___________________________________________________ Date of Birth ____________ SS# __________________ First Full Middle Name Maiden LastYes No FORMCHECKBOX FORMCHECKBOX Are you presently subject to an indictment, criminal information, arraignment, or other means by which formal criminal charges are brought in any jurisdiction? If YES, must provide detailed information on a separate sheet. FORMCHECKBOX FORMCHECKBOX Have you ever been arrested in the past six months for any criminal offense. If YES, all arrests and charges must be disclosed and explained on an attached sheet. FORMCHECKBOX FORMCHECKBOX For any criminal offense (other than a minor vehicle violation) have you ever: 1) been convicted; 2) plead guilty; 3) plead nolo contendere; 4) been placed on pretrial diversion; or 5) been placed on any form of parole or probation (including probation before judgment)? If YES, must provide detailed information on a separate sheet. FORMCHECKBOX FORMCHECKBOX Are you presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency? FORMCHECKBOX FORMCHECKBOX If you are at least a 50% or more owner of the applicant business, are you more than 60 days delinquent on any obligation to pay child support arising under an administrative order, court order, repayment agreement between the holder and a custodial parent, or repayment agreement between the holder and a state agency providing child support enforcement services? FORMCHECKBOX FORMCHECKBOX Do you have a trust? If YES, provide an executed copy of the Trust(s). FORMCHECKBOX FORMCHECKBOX Are you, any of your children, your parents or your spouse employed by, director of, officers of or stockholders of the participating bank of the SBA, SCORE, ACE or any Federal Agency? If yes, please provide the name and address of the person and the office where employed. FORMCHECKBOX FORMCHECKBOX Are you or your business involved in any pending lawsuits? If YES, provide documentation. FORMCHECKBOX FORMCHECKBOX Do you have ownership, stock ownership, management control, previous relationships with or ties to another business or contractual relationship in any other businesses? If YES, please complete Affiliate Form (form attached) FORMCHECKBOX FORMCHECKBOX Do you or any of your affiliated businesses have any existing debt with SBA guarantees? If YES, provide detailed information. FORMCHECKBOX FORMCHECKBOX Have you or any of your affiliate businesses ever caused a loss to the Government from prior federal assistance? FORMCHECKBOX FORMCHECKBOX Have you ever filed for corporate or personal bankruptcy or been involved in insolvency proceedings? If YES, please provide a copy of the bankruptcy documentation. FORMCHECKBOX FORMCHECKBOX A current credit report will be request on each borrower. Are there entries on the credit report which will require an explanation? Is so, please attach a sheet explaining the circumstances of these entries.I certify that the above information is valid and correct to the best of my knowledge.Signature ___________________________________________ Date ________________ Personal ResumeRequired for all key management staff involved in day-to-day operations and all persons with 20% or more ownership in the operating company and borrowing entity.Name _____________________________________________________________ First Full Middle Name Maiden LastAddress __________________________________________________________ City________________ State _____ Zip ________Home Phone Number ___________________ Cell Phone _________________ Email ____________________________________EducationInstitution Dates Attended MajorDegree or Certificate______________________________ ________ - ________ _________________________ ______________________________________________________ ________ - ________ _________________________ ______________________________________________________ ________ - ________ _________________________ ________________________Work ExperienceEmployer _________________________________ From / To Date _____________________ Title __________________________ Duties _______________________________________________________________________________ Salary $________________Employer _________________________________ From / To Date _____________________ Title __________________________ Duties _______________________________________________________________________________ Salary $________________Employer _________________________________ From / To Date _____________________ Title __________________________ Duties _______________________________________________________________________________ Salary $________________Employer _________________________________ From / To Date _____________________ Title __________________________ Duties _______________________________________________________________________________ Salary $________________Employer _________________________________ From / To Date _____________________ Title __________________________ Duties _______________________________________________________________________________ Salary $________________Other Business Related interest or Activities (List any training, certification, or business related interest or activities)____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Personal Income & Expense AnalysisThis form needs to be filled out by all persons owning 20% or more of the operating company and borrowing entity. Name(s):?INCOMES:MONTHLYANNUALLYAvailable Draw(NP + Depreciation)??Gross Salary(Principal)??Gross Salary(Spouse)??Rental Income(Gross)??Interest Income(Recurring)??Alimony(Recurring)??Other Income: __________(Recurring)??TOTAL INCOME$0 $0 EXPENSES:Residence Expense(Rent or P&I)??Rental Mortgages(P&I)??Rental Expenses(Cash Exp. Less P&I)??Auto Loan(s)(All)??Installment Loan(s)(All)??Revolving Credit(All)??Utilities/Phone(Estimate)??Insurance(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( )??(Miscellaneous expenses are typical range is 5% - 10% of total income)TOTAL EXPENSES$0 $0 NET DISCRETIONARY INCOME$0 $0 COVERAGE RATIO (INCOME/EXPENSE)#DIV/0!#DIV/0!Signature __________________________________________Date?Signature __________________________________________Date?PERSONAL FINANCIAL STATEMENTTo be completed for each owner of the applicant business with 20% or more ownership interest, key management staff, and all officers, even if they are not owners. Use a separate page for each individual, including individually for husband and wife. Double mouse click the form below to access the two-page fillable form. The fillable form is also available on SCKEDD’s website. PERSONAL FINANCIAL STATEMENT (continued) Schedule of Business Debt Name: _________________________As of: _______________, 20___Debts listed must correspond to the current balance sheet provided with this loan application.Provide separate sheet for the operating company and borrowing company.Loan No.CreditorOriginal AmountOriginal DateCurrent BalanceStatusMaturity DateInterest RateMonthly PaymentCollateral??????????????????????????????????????????????????Line of Credit Information??????????????????????????????Signature ___________________________________________ Date ________________AUTHORIZATION AND INDEMNIFICATION AGREEMENTI/we hereby authorize South Central Kansas Economic Development District, Inc., (hereafter referred to as “CDC” Certified Development Company) 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 credit worthiness for any purpose related to our credit transaction with them. I/we hereby certify that the enclosed application information including attachments/exhibits are valid and correct to the best of my/our knowledge.I/we hereby authorize the CDC to furnish relevant information to all necessary sources including various federal, state, county, and conventional funding opportunities to obtain the best sources for the project. I/we hereby authorize the CDC to furnish relevant information to CDC’s Loan Review Committee(s) for decision; and, to furnish relevant information to the CDC’s Board of Directors and various federal, state, and county agencies, officials and economic development representatives for CDC’s reporting requirements regarding area economic development.I/we authorize any company, partnership, corporation, organization or entity of whatever kind to provide the CDC with any credit, financial or personal information held by such entity and requested by the CDC.I/we further agree that I shall indemnify and hold the CDC harmless from any claim or cause of action arising because of incorrect, inaccurate or incomplete information furnished by me, whether the furnishing of such incorrect, inaccurate or incomplete information was accidental or intentional and in consideration of the CDC’s assistance, I waive all claims against the CDC, its personnel or counselors arising from this assistance.The small business applicant and its principals as individuals, agree to indemnify and hold South Central Kansas Economic Development District, Inc. (CDC) and/or its agents and assigns harmless from and against, any damages, cost, liability or expense attributable to release, threatened release, discharge, manufacture, production, storage or disposal or the presence of hazardous toxic substances, on or under borrower’s property or property in which borrower has an interest including adjoining real property and based upon claims assertible by local, state, and federal governmental authority or other third parties against CDC or its assigns.This indemnification will specifically survive, and is entirely independent of the debtor’s contractual obligation to repay the primary obligation held by CDC as amended, extended, or renewed by CDC, prepayment in full of the borrower’s indebtedness to CDC; and release of CDC liens on borrower’s real or personal property by payment, foreclosure, or other action including CDC’s discretionary abandonment of lien.Business Applicant:___________________________________________________________________________________________________ ______________________________Signature/ Title Date___________________________________________________________________________________________________ ______________________________Signature/ Title Date___________________________________________________________________________________________________ ______________________________Signature/ Title Date___________________________________________________________________________________________________ ______________________________Signature/ Title DateAs Individuals:___________________________________________________________________________________________________ ______________________________Signature Date___________________________________________________________________________________________________ ______________________________Signature Date___________________________________________________________________________________________________ ______________________________Signature Date___________________________________________________________________________________________________ ______________________________Signature Date ................
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