Albany Community Together, Inc
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: ___________________ |
|Email Add: ______________________________________________ |
| |
|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 |
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|Do you have any of the following? (Please check all that apply) |
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|□ Business License □ Sellers Permit/Retail # □ Registered DBA □ Patent □ Trademark □ Copyright □ Business Plan |
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|BUSINESS FORM: |
|□ Sole Proprietorship □ Partnership □ Corporation □ S-Corporation □ Limited Liability Company |
|FINANCE INFORMATION |
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|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) |
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|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: $ ______________ |
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|Bank of Business Account (w/complete address):_________________________________________________________________ |
|EMPLOYEE INFORMATION |
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|Do you have employees? □ Yes □ No |
|If Yes, total number of employees in year: |
|Full-Time: ___ Part-Time: ___ |
|Seasonal/Temp: ___ . |
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|____________________________________________ Date: _______________ |
|Signature |
|SECTION II |
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|USES OF FUNDS STATEMENT |
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|+Please include proposed uses of loan funds requesting from ACT! |
|USE OF PROCEEDS: |
|LOAN REQUESTED: |
|(ENTER GROSS DOLLAR AMOUNT) |
|ROUNDED TO NEAREST HUNDREDS |
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|LAND/BUILDING ACQUISITION |
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|NEW CONSTRUCTION/RENOVATION |
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|ACQUISITION OF MACHINERY/EQUIPMENT |
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|FIXTURES/SIGNAGE |
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|INVENTORY PURCHASE |
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|WORKING CAPITAL (INCLUDING ACCOUNTS PAYABLES) |
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|ACQUISITION OF EXISITING BUSINESS |
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|ALL OTHERS |
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|TOTAL LOAN REQUESTED |
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|TERM OF LOAN REQUESTED |
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|NAME & OCCUPATION |
|MAILING ADDRESS |
|TOTAL FEES PAID |
|FEES DUE |
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|Please provide the following information for all consultants/advisors paid to assist with this application: |
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|_______________________________________________ _____________________________________________ |
|SIGNATURE OF PREPARER (S) IF OTHER THAN APPLICANT IF APPLICANT IS A PROPRIETOR OR GENERAL |
|PARTNER (S), SIGN HERE |
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|_____________________________________________ |
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|___________________________________________________________________________________________ |
|IF APPLICANT IS A CORPORATION, SIGN HERE |
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|BY: _________________________________________ ATTESTED BY: ___________________________________ |
|SIGNATURE OF PRESIDENT SIGNATURE OF CORPORATE SECRETARY|
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|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. |
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|Name (Printed): _____________________________ Name (Printed): _________________________________ |
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|Signature: __________________________________ Signature: _____________________________________ |
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|Date: ______________________________________ Date: _________________________________________ |
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|SECTION III |
|Previous ACT! or other Government Financing: If you, any principals, or affiliates have ever requested Government Financing, complete the following: |
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|Name of |
|Agency |
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|Original Amount |
|of Loan |
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|Date of Request |
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|Approved |
|or |
|Declined |
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|Balance |
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|Current or Past Due |
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|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 |
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|Original Amount |
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|Original Date |
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|Present Balance |
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|Rate of Interest |
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|Maturity Date |
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|Monthly Payment |
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|Security |
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|Current |
|Or |
|Past Due |
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|MANAGEMENT (Proprietor, partners, officers, directors, and all holders of outstanding stock – 100% OF OWNERSHIP MUST BE SHOWN). |
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|Name, Social Security # |
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|Mailing Address (Complete) |
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|% Owned |
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|Position |
|Held |
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|Attach supplental sheet if necessary. |
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