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:_____________________________________________________________________________ |

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|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: ______________________________________________ |

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|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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