Dental Financing Application

[Pages:9]1Items include checks paid (including electronified checks), checks deposited, deposit tickets, ACH debits, and ACH credits. An electronified check is a check that has been used as a source of information to enable a one-time payment from your account in the form of an ACH debit. An excess item fee of $0.50 per item over 500. 2? 2017 MasterCard. MasterCard, Debit MasterCard, and the MasterCard brand marks are trademarks of MasterCard International Incorporated. Certain terms, conditions, and exclusions apply. See and for complete benefit terms and conditions. 3Premier Banking is for personal use only. 4If you use an ATM that is not owned by Sandy Spring Bank to withdraw funds from your Premier Banking account and are assessed an ATM surcharge fee by the owner of the machine, we will credit your Premier Banking account for the surcharge fee, up to 4 ($12 maximum) per monthly statement cycle. Surcharge refund does not apply to interchange fees on international transactions. *Not FDIC Insured ? No Bank Guarantee ? Not a Bank Deposit ? Not Insured by Any Government Agency ? May Lose Value

17801 Georgia Avenue, Olney, Maryland 20832 301.774.6400 ?

Member FDIC

Banking for the Dental Professional

Products and services that can help you meet your business and financial goals.

Whatever the life-stage of your dental practice -- whether you are just starting out, expanding, or maintaining your practice -- Sandy Spring Bank offers an array of products that can meet your financial services needs.

We understand the specialized needs of Dental Professionals and will work with you as a true financial partner. The products and services we recommend will offer you a full range of solutions designed to help you achieve your business objectives.

With everything from loans, lines of credit, checking accounts and treasury management services to wealth management, insurance and employee benefit programs -- Sandy Spring Bank has all the services you need today and in the future.

Financing Solutions

At Sandy Spring Bank, we can provide the financing you need for working capital as well as practice acquisition and startup, mortgages, leasehold improvements/expansion, and more.

Commercial Loans and Lines of Credit

Regardless of whether you're just starting out, buying into an established practice, or growing your individual practice, we have the right financing option for you.

Checking Solutions

Our checking account products are designed with your needs in mind. We'll help you select the one that is right for you.

Flex Business Checking

The business checking account to meet the needs of your practice now and as your practice grows. Flex Business Checking also provides you additional valuable and money saving benefits.

Monthly Statement Transaction Tiers

Number of Transaction

Items1

0 - 100

101 - 300 300 and above

Monthly Maintenance

Fee

None

$10 $20

Minimum Monthly Average Balance to Avoid the Fee

No Minimum Required

$5,000

$15,000

? Remote deposit capture for a fixed monthly fee of $50 which includes a free single document scanner and up to 100 checks scanned per month at no charge.

? Free Business Debit MasterCard? with Easy Savings Rebate Program2 and access to over 55,000 ATMs surcharge-free.

Commercial Checking

As your business grows, our Commercial Checking Account offers expanded and comprehensive services.

? Offset fees with an earnings credit on checking balances.

? Specialized lockbox services for patient remittances with image capability.

? Remote deposit capture to facilitate check collections.

? Wire Transfer and ACH access through ebiz.

? Free Business Debit MasterCard with Easy Savings Rebate Program2 and access to over 55,000 ATMs surcharge-free.

? Premier Banking personal checking accounts with no monthly maintenance fees (for account signers).3

Workplace Banking

At Sandy Spring Bank, we don't forget about your employees. Our Workplace Banking offers your employees special rewards and benefits -- including free checking.

Personal Banking Products and Services

Sandy Spring Bank can offer both you and your employees a complete package of banking services.

Personal Checking and Savings

We offer a variety of checking accounts including:

My Free Banking

Checking with no minimum balance requirement and unlimited check writing, plus BankXpress Online Banking with Bill Pay, Mobile Banking with Mobile Deposit, access to more than 55,000 ATMs and a Debit MasterCard -- all free.

Premier Banking

A comprehensive package of banking services including: 4 ATM surcharge refunds per monthly statement cycle,4 access to over 55,000 ATMs surcharge-free, unlimited check writing, BankXpress Online Banking with Bill Pay, free Premier Checks, World Debit MasterCard, discounts on other Bank products -- and it even pays interest.

Other Banking Services

? Money Market Accounts ? Certificates of Deposit ? Personal loans and lines of credit ? Mortgage loans

Insurance Services*

Sandy Spring Bank offers a variety of insurance products through its subsidiaries -- Sandy Spring Insurance and Neff & Associates. At Sandy Spring Insurance, we can help you prepare for the unexpected. Sound planning and the proper insurance could help keep your practice running -- and guarantee future financial security for your family. Sandy Spring Insurance offers a full range of business insurance policies including:

? Worker's Compensation

? Commercial Umbrella

? Life and Health

? Property & Casualty

Medical Malpractice

The insurance professionals at Neff & Associates can review your existing Professional Liability Insurance and make recommendations to ensure that your practice is properly covered.

Wealth Management*

We provide access to a full range of services for both your practice and your personal investment needs. Certified Financial Planners (CFPs) with West Financial Services, Inc., a subsidiary of Sandy Spring Bank specializing in financial planning for medical professionals, can work with you to develop a comprehensive personal plan in such ares as tuition planning, cash flow management, estate planning, and more.

Additional Services

? Health Savings Accounts (HSAs) ? Merchant Services (competitive rates for your Credit

Card Processing) ? Employee Benefits ? Payroll and Human Resources

Management Solutions

Contact us at 866.867.1570 to discuss the many ways Sandy Spring Bank can help your

practice.

Dental Professional Financing Application

Thank you for applying to Sandy Spring Bank. Please fill out this form in as much detail as possible, attach it to any applicable supporting information, and return everything to your Relationship Manager or to Sandy Spring Bank, Small Business Loan Center, 6831 Benjamin Franklin Drive, Columbia, Maryland, 21046. Each guarantor must complete and sign a separate application. If you have any questions, please contact your Relationship Manager, or contact the Commercial Business Center at (866) 8671570.

Important Information about Procedures for Opening a New Account To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask you for your name, address, date of birth, and other information that allows us to identify you. We may also ask to see your driver's license or other identifying documents.

Application Checklist

All requests should include the basic information and the following: A. (for equipment or leasehold improvements) B. (for real estate) C. (for practice purchase)

Basic information (needed for all requests) o Completed and signed application o Three years of personal and business tax returns with all schedules (two years if total request below $500,000) o Year-to-date practice financial statements

A. Financing equipment or leasehold improvements o Invoice(s) and/or construction contract(s)

B. Financing real estate o Draft purchase agreement / letter of intent o Existing leases (if applicable)

C. Financing practice purchase o Draft purchase and sales agreement(s) / letter of intent o Practice Valuation o Draft lease o Draft employment agreements o Production Reports o Curriculum vitae

Additional Information Need Prior to Closing

o Sandy Spring Bank listed as beneficiary on life insurance policy o Sandy Spring Bank listed as loss payee on business personal property insurance policy o Sandy Spring Bank listed as loss payee on hazard insurance policy (if financing real estate) o Verification of disability insurance policy o Verification of malpractice insurance policy o State dental license o Articles of Incorporation and By-laws or Operating Agreement o Signed IRS form 4506-T

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Financial Team Contact List

Accountant

Name: ____________________________ Phone: ____________________________ E-mail: ______________________________

Attorney

Name: ____________________________ Phone: ____________________________ E-mail: ______________________________

Insurance Agent

Name: ____________________________ Phone: ____________________________ E-mail: ______________________________

Practice Broker

Name: ____________________________ Phone: ____________________________ E-mail: ______________________________

Real Estate Broker

Name: ____________________________ Phone: ____________________________ E-mail: ______________________________

Other:___________________ Name: ____________________________ Phone: ____________________________ E-mail: ______________________________

Borrower Information

Practice Name:________________________________________________ Tax ID#:____________________________________________________________________

Practice Address: ____________________________________________ City, State, Zip: ____________________________________________________________

Practice Phone: ______________________________________________ E-mail: ____________________________________________________________________

Ownership: _______________________________________ % _________ Entity Status: o C-Corp o S-Corp o LLC/LLP

_______________________________________ % _________

o Partnership o Sole Proprietorship

Membership: o Maryland State Dental Association o Northern Virginia Dental Society o Other:______________________________

Financing Request

Application Date: _____/_____/_____

Requested Closing Date: _____/_____/_____

Amount:

Practice Acquisition $____________________

Leasehold Improvements

$____________________

Practice Refinance

$____________________

Real Estate

$____________________

New Equipment

$____________________

Other: ______________________

$____________________

Equipment Refinance $____________________

Total

$____________________

Seller financing amount, if any: $__________________

Term (months): o 24 o 96

o 36 o 120

o 48 o 180

o 60

o 72

o Other _______________

o 84

Collateral: Please list collateral available to secure loan request(s) along with descriptions and values.

Type

Description

Value

Existing Liens

___________________________________ _____________________________________________________ $_______________ o Yes o No

___________________________________ _____________________________________________________ $_______________ o Yes o No

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Acquisition Practice Information (tell us about the practice you are buying)

Type of acquisition: o Entity purchase o Asset purchase o Practice merger o Client list purchase In-process Complete N/A Additional Information

Visited practice

o

o

o

________________________________________________

Met with staff

o

o

o

________________________________________________

Negotiated purchase/sales agreement(s)

o

o

o

________________________________________________

Negotiated employment agreement(s)

o

o

o

________________________________________________

Negotiated lease

o

o

o

________________________________________________

Insurance credentialing

o

o

o

________________________________________________

Relocate primary residence

o

o

o

________________________________________________

Create new legal entity for purchase

o

o

o

________________________________________________

Obtain life and disability insurance

o

o

o

________________________________________________

Will the current dentist stay? o Yes o No

If yes, what will be the compensation?__________________________________

Will you hire an associate? o Yes o No

If yes, what will be the compensation?__________________________________

Do you own another practice? o Yes o No

If yes, _________________ miles between the two practices

Do you have a non-compete contract? o Yes o No

If yes, _________________ miles and ________________ years

Dentists #: _______________ Hygienists #: _______________ Office staff #: _______________ Active patients #: _______________

Specialties: o General/Family o Periodontics o Endodontics o Orthodontics o Surgery o Other ____________________

Days worked per week: #________ Patients per day: #________ Full Schedule o Yes o No Average charge per visit $_________

Services breakdown: Dentistry _______%

Hygiene _______%

Other_______________ _____%

Collections breakdown: Fee for service _______%

PPO _______%

HMO _______%

Planned expansion or expenditures ________________________________________________________________________________________________________

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Current Practice Information (tell us about the practice you have)

Date of formation: ____/____/____ Dentists #: _______________ Hygienists #: _______________ Office staff #: _______________

Specialties: o General/Family o Periodontics o Endodontics o Orthodontics o Surgery o Other ___________________

Days worked per week: #________ Patients per day: #________ Full Schedule o Yes o No Average charge per visit $__________

Services breakdown: Dentistry _______%

Hygiene _______%

Other_______________ _____%

Collections breakdown: Fee for service _______%

PPO _______%

HMO _______%

Production % paid to Associate(s) _______%

Production % paid to Hygienist(s) _______%

Planned expansion or expenditures __________________________ Accept Credit Cards o Yes o No Primary Bank________________________

Existing debt: Please list any existing debt that is not being consolidated with this request, including student debt or student loan debt.

Name of creditor

Line or loan Secured

Balance

Rate Payment

Maturity date

__________________________ _________________ o Yes o No $_______________ _____% $_______________ ____/____/____

__________________________ _________________ o Yes o No $_______________ _____% $_______________ ____/____/____

If yes, please attach a written explanation:

Has the practice ever filed bankruptcy?

o Yes o No

Is the practice involved in any litigation, at this time?

o Yes o No

Are any taxes or debts currently past due?

o Yes o No

Is the practice liable for any debt not shown above?

o Yes o No

Has the practice incurred a loss in any of the last 3 years? o Yes o No

Doctor Information (please complete for each guarantor) Name: __________________________________________________ Social Security #: ______________________________ Date of Birth: ____/____/____ Home address:_________________________________________ City:_______________________________________ State: ___________ Zip:_______________ Phone number: _____________________________________________________________________________ Time at current address: ____________________ Dental license #: _________________ State: __________ Have you ever had an action against your license? o Yes o No Years practicing #: _______________ School and Degree(s): ________________________________________ E-mail: ______________________________ Are you, or will you continue, working as an associate in another practice? o Yes o No

---Complete only if applying jointly--Name: __________________________________________________ Social Security #: ______________________________ Date of Birth: ____/____/____ Home address:_________________________________________ City:_______________________________________ State: ___________ Zip:_______________ Phone number: _____________________________________________________________________________ Time at current address: ____________________ Occupation: ___________________________ Title: _____________________ Time in business: ________________ E-mail: ____________________________

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Doctor Information Continued

Statement of personal financial condition as of: ____/____/____

The assets, liabilities, income and expenses described in this financial statement are (check the appropriate box):

o Individual If you are applying for credit individually, list all your own individual income, expenses, assets, and liabilities.

o Joint

If you are applying for credit jointly, list all of the income, expenses, assets, and liabilities for both parties.

o We intend to apply for Joint credit.

Assets

Cash

In This Bank

(Schedule 1) In Other Banks

Securities

Marketable Securities

(Schedule 2) Non-Marketable Securities

Loans Receivable

Real Estate

Primary Residence

(Schedule 5) Wholly-Owned Real Estate

Partially-Owned Real Estate

Other Partnership Interests

Automobiles and Vehicles

Cash Value ? Life Insurance (Schedule 3)

Retirement Funds and Deferred Compensation

Other Assets

Total Assets

Liabilities

Credit Card Balances

Accounts Payable

Notes Payable To This Bank

(Schedule 4) Other Notes Payable

Mortgages

Primary Residence

Payable

Home Equity Loans

(Schedule 5) Wholly-Owned Real Estate

Partially-Owned Real Estate

Income Taxes Outstanding

Other Taxes Outstanding

Other Liabilities

Total Liabilities Net Worth (Assets less Liabilities)

Sources of Income Salary & Wages Interest Income Dividend Income Business Income Real Estate Income Other*

Subtotal Non-recurring Sales of Assets Commissions

20___

Total

20___

Annual Expenditures Income Taxes Estimated Living Expenses Real Estate Expenses Alimony, Child Support, Other Education or Child Care Expenses Other

Subtotal Residence Mortgage Payment Rent Payments Car and/or Vehicle Payments Home Equity Line/Loan Payments Credit Card Payments Other Real Estate Payments Other

Total

20___

20___

*You do not have to include information about income from alimony, child support or separate maintenance payments unless you want us to consider this income in connection with this application for credit.

Statement of Contingent Liabilities: Contingent liabilities are financial obligations of other individuals, partnerships, or companies which you have endorsed, guaranteed, or otherwise agreed to or have a statutory obligation to honor in the event of certain contingencies. They may also be any direct obligations that are not reflected in the balance sheet above that you will be required to honor in the event of certain contingencies. These include obligations to Sandy Spring Bank as well as to other banks or creditors of any kind. You must disclose all such guarantees, endorsements, etc. below.

o I have no contingent liabilities.

Type of Obligation

Name of Creditor

Amount

Maturity date

Explanation of Purpose

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Supporting Schedules ? Please state all of the owners for each account listed.

Schedule 1 ? Depository Accounts Names on Account

Depository Institution Total Balances in Accounts

Balance

o Yes o No o Yes o No o Yes o No

Type of Account Pledged

Schedule 2 ? Marketable Securities Security or Fund Title in Name(s) Of

Shares # Share Value Total Market Value

Total Market Value

Pledged

o Yes o No o Yes o No o Yes o No

Restricted

o Yes o No o Yes o No o Yes o No

Schedule 3 ? Life Insurance Carried

Name of Insurer

Policy in Name(s) Of

j

Beneficiary

Amount

Loans Cash Value

Total Face Amount and Policy Loans

Schedule 4 ? Notes Payable (Exclude Mortgage Listed in Schedule 5)

Name of Creditor

Type of Loan

Original

Current Rate

Maturity Payment Collateral

Total Current Balance and Monthly Payments

Schedule 5 ? Wholly-Owned Real Estate

Address

State

Title

Type Residence

Value Balance Lender Rate Payment

Total Value and Mortgage Balances

Schedule 6 ? Partially-Owned Real Estate

Address

State

Title

Type Residence

Value

Balance Lender Rate Payment

Total Value and Mortgage Balances

Citizenship/Residency U.S. Citizen Permanent Resident Alien*

Applicant Co-Applicant ____________ ___________ ____________ ___________

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