Community Futures Manitoba
APPLICATION FOR FINANCIAL ASSISTANCETHE FOLLOWING DOCUMENTS ARE TO BE INCLUDED WITH YOUR LOAN APPLICATION:FOR ALL APPLICANTS:Copy of Driver’s License Current Personal Resume of Key Personnel Involved in Business FOR APPLICANTS WHO ALREADY OWN OR ARE PURCHASING AN EXISTING BUSINESS:Financial business statements for the past two years Aged accounts payable and accounts receivable lists including names, amounts and status Any other supporting documents, i.e. sales agreements, contracts, purchase agreements, appraisals RECEIPT OF THIS APPLICATION DOES NOT CONSTITUTE ACCEPTANCE BY COMMUNITY FUTURES WESTMANALL PARTS OF THE BUSINESS LOAN APPLICATION AND BUSINESS PLAN ARE TO BE COMPLETELY FILLED OUT. NO LOAN APPLICATION WILL BE ACCEPTED WITHOUT ALL THE APPROPRIATE ATTACHMENTS.PERSONAL INFORMATIONFULL LEGAL NAME: ______________________________________________________________FIRSTMIDDLELASTMAILING ADDRESS: _____________________________________________________________BOX #TOWNPOSTAL CODESTREET ADDRESS: _______________________________________________________________HOUSE #STREETTOWNPHONE: (______) ______-___________ (______) ______-____________DAYTIME NUMBEREVENINGS/WEEKENDS NUMBEREMAIL: ________________________________________________________________________SOCIAL INSURANCE NUMBER: _____________________________________________________DRIVER’S LICENSE NUMBER: ______________________________________________________DATE OF BIRTH: ___________________ ARE YOU A CANADIAN CITIZEN: _____ YES _____ NOMONTHDAYYEARSPOUSAL INFORMATIONFULL LEGAL NAME: ______________________________________________________________FIRSTMIDDLELASTDATE OF BIRTH: _________________________ SOCIAL INSURANCE NUMBER: ______________MONTHDAYYEARPRESENT EMPLOYER: _____________________________________ # OF YEARS: ___________POSITION: ________________________________ SALARY: ___________________________EMPLOYMENT INFORMATIONPRESENT EMPLOYER: ______________________________________ # OF YEARS:__________POSITION: _______________________________ SALARY: ____________________________PREVIOUS EMPLOYER: _____________________________________ # OF YEARS: __________POSITION: ____________________________________ SALARY: ______________________BUSINESS INFORMATIONBUSINESS NAME: _______________________________________________________________MAILING ADDRESS: _____________________________________________________________BOX #TOWNPOSTAL CODEBUSINESS LOCATION: ____________________________________________________________IS YOUR BUSINESS NAME REGISTERED: ____YES ____NO BUSINESS #:____________________THE BUSINESS IS A: SOLE PROPRIETORSHIP: ____ / PARTNERSHIP:____ / CORPORATION:_____FISCAL YEAR END: ________________ PROJECTED BUSINESS START-UP DATE: _____________MONTHMONTH , YEARLIST ALL OWNERS (SOLE PROPRIETORSHIP / PARTNERSHIP) OR PRINCIPALS (INCORPORATED):__________________________________________________NAMEROLE / FUNCTION % OF OWNERSHIP__________________________________________________NAMEROLE / FUNCTION % OF OWNERSHIP__________________________________________________NAMEROLE / FUNCTION % OF OWNERSHIPLOAN INFORMATIONLOAN AMOUNT REQUESTED: $_____________________________________________________PLEASE PROVIDE DETAILS REGARDING THE PURPOSE OF YOUR LOAN REQUEST:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________WHAT IS THE TOTAL COST OF YOUR PROJECT? $__________________HOW WILL THE FUNDS BE USED? (PLEASE BE SPECIFIC)BUILIDNG $____________________OPERATING $____________________EQUIPMENT $____________________SUPPLIES$____________________OTHER: ________________$____________________OTHER: ________________$____________________WHAT IS YOUR CONTRIBUTION TO THE BUSINESS?FINANCIAL$____________________OTHER: _______________$____________________OTHER: _______________$____________________PLEASE IDENTIFY YOURSELF AS ONE OF THE FOLLOWING:YOUTHABORIGINALDISABLEDOTHERPERSONAL MONTHLY COST OF LIVING STATEMENTNET MONTHLY INCOMEAPPLICANT$SPOUSE$OTHER$ TOTAL MONTHLY INCOME$MONTHLY EXPENSESVEHICLE (INSURANCE, FUEL, REPAIR)$CABLE$CLOTHING$GROCERIES$LOAN PAYMENTS:$ VEHICLE$ CREDIT CARD$ OTHER:____________ (EG. LINE OF CREDIT)$RECREATION AND ENTERTAINMENT$RENT OR MORTGAGE$TELEPHONE$UTILITIES (HEAT, WATER, HYDRO)$INSURANCE$OTHER: ___________$OTHER: ___________$ TOTAL MONTHLY EXPENSES$NET MONTHLY SURPLUS (INCOME–EXPENSES)$I HAVE MADE BEST EFFORTS TO ACCESS FUNDS FROM OTHER SOURCES WITHOUT SUCCESS: ________(INITIALS)REASON FOR REJECTION: _________________________________________________________REFERENCESNAMEOCCUPATIONPHONE NUMBERBANKERACCOUNTANTPERSONAL REFERENCEOTHEROTHERINSURANCE INFORMATIONDO YOU CURRENTLY HOLD A LIFE INSURANCE POLICY? ___YES ____NOIF YES: AMOUNT: $_______________ COMPANY: _______________DO YOU CURRENTLY HAVE BUSINESS INSURANCE IN PLACE? ____YES ____NOIF YES: AMOUNT: $_______________ COMPANY: _______________DO YOU CURRENTLY HAVE SHAREHOLDERS INSURANCE? (IF INCORPORATED) ____YES ____NOIF YES: AMOUNT: $_______________ COMPANY: _______________HOW WERE YOU REFERRED TO COMMUNITY FUTURES? (PLEASE CHECK ALL THAT APPLY)ANOTHER LENDERAN ACCOUNTANT OR LAWYERWORD OF MOUTHADVERTISINGOTHER:__________________STATEMENT OF ASSETSCASH HOLDINGS / INVESTMENTSBANK / BRANCHACCOUNT #AMOUNT$$$REAL ESTATEADDRESSOWNER(S)PURCHASE PRICEPRESENT VALUE$$$$$$VEHICLESTYPE & YEARPURCHASE PRICEPRESENT VALUE$$$$$$OTHER MAJOR ASSETSDESCRIPTIONPURCHASE PRICEPRESENT VALUE$$$$$$STATEMENT OF LIABILITIESLOANSLENDERADDRESSTERMSSECURITYINTEREST RATEBALANCE%$%$%$MORTGAGESLENDERADDRESSMONTHLY PAYMENTMATURITY DATEINTEREST RATEBALANCE%$%$%$CREDIT CARDSNAME OF CARDDETAILSMONTHLY PAYMENTCREDIT LIMITINTEREST RATEBALANCE OWING%$%$%$OTHER LIABILITIESDESCRIPTIONDETAILSMONTHLY PAYMENTMATURITY DATEINTEREST RATEBALANCE OWING%$%$%$STATEMENT OF NET WORTHASSETSAMOUNTLIABILITIESAMOUNTCASH$BANK LOANS$LIFE INSURANCE (CASH VALUE)$MORTGAGES$REAL ESTATE$CREDIT CARDS$VEHICLES$LOANS$STOCKS. BONDS, GICs$LINES OF CREDIT$HOUSEHOLD AND PERSONAL$OTHER LIABILITIES$OTHER ASSETS$OTHER LIABILITIES$TOTAL ASSETS (A)$TOTAL LIABILITIES (B)$NET WORTH (A MINUS B)$DECLARATION AND AUTHORIZATIONI/WE CONSENT TO THE EXCHANGE WITH OTHERS OF CREDIT INFORMATION BY THE CF AT ANY TIME AND HEREBY AGREE TO INDEMNIFY AND SAVE HARMLESS THE CF FROM ALL CLAIMS ARISING FROM SUCH EXCHANGE. I/WE ALSO CONFIRM THAT I/WE HAVE APPROACHED THE CONVENTIONAL LENDING SOURCES RELATIVE TO OUR APPLICATION FOR FINANCING, AND HAVE BEEN UNABLE TO SECURE ADEQUATE FINANCING UNDER REASONABLE TERMS AND CONDITIONS. I/WE, THE APPLICANT(S), ARE NOT IN MY/OUR KNOWLEDGE IN CONFLICT OF INTEREST WITH THE REGULATIONS OF THE CF, MEANING: A DIRECTOR OF A CF OR A MEMBER OF ANY COMMITTEES OF A CF; THE SPOUSE, CHILD, SIBLING, OR PARENT OF A DIRECTOR OF A CF OR A MEMBER OF ANY COMMITTEES OF A CF OR A MEMBER OF A CF STAFF; OR A MEMBER OF THE HOUSE OF COMMONS. I/WE THE APPLICANT, ARE NOT INVOLVED IN ANY LITIGATION PROCEEDINGS AND HAVE NEVER FILED A CLAIM FOR BANKRUPTCY, UNLESS OTHERWISE DISCLOSED. I DECLARE THAT THE ATTACHED PAGES ARE A TRUE STATEMENT OF MY AFFAIRS, THAT THERE ARE NO JUDGMENTS OR OTHER ACTIONS OUTSTANDING AGAINST ME, EXCEPT THOSE RECORDED HEREIN, THAT ALL REAL ESTATE IS REGISTERED SOLELY IN MY NAME, UNLESS OTHERWISE STATED, THAT THE INFORMATION HEREIN IS PROVIDED FOR THE EXPRESS PURPOSE OF OBTAINING FINANCIAL ASSISTANCE FROM THE CF. I/WE AUTHORIZE THE CF TO OBTAIN ANY INFORMATION YOU MAY REQUIRE RELATIVE TO THIS APPLICATION FROM ANY SOURCES TO WHICH YOU MAY APPLY AND EACH SOURCE IS AUTHORIZED TO PROVIDE YOU WITH SUCH INFORMATION. YOU ARE FURTHERMORE AUTHORIZED TO DISCLOSE, IN RESPONSE TO DIRECT ENQUIRIES FROM ANY OTHER LENDERS OR CREDIT BUREAU, SUCH INFORMATION ON MY LOANING ACCOUNT AS YOU CONSIDER APPROPRIATE, AND I AGREE TO INDEMNIFY YOU AGAINST AND SAVE YOU HARMLESS FROM ANY AND ALL CLAIMS IN DAMAGES OR OTHERWISE ARISING FROM SUCH DISCLOSURE ON YOUR PART. I UNDERSTAND THAT THE CF IS NOT ACTING EXCLUSIVELY FOR ME/US OR MY/YOUR VENTURE AND THAT IT RESERVES THE RIGHT TO PROVIDE FINANCIAL AND NON-FINANCIAL ASSISTANCE TO INDIVIDUALS OR CORPORATIONS WHICH COULD BE SEEN AS MY DIRECT OR INDIRECT COMPETITION WITHOUT FURTHER NOTICE TO ME/US, AS IT MAY DECIDE IN ITS UNFETTERED DISCRETION. IN COMPLETING AND SUBMITTING THIS DOCUMENT, THE APPLICANT(S) RECOGNIZES, ACKNOWLEDGES, AND AUTHORIZES THE COMMUNITY FUTURES TO USE AND SHARE THE INFORMATION CONTAINED IN THIS DOCUMENT WITH PERTINENT FINANCIAL PARTNERS, INVESTMENT BOARD MEMBERS, AND OTHER GOVERNMENT AGENCIES AS REQUIRED TO RENDER REQUESTED TECHNICAL AND FINANCIAL ASSISTANCE. I AGREE AND CONSENT TO TAKE RESPONSIBILITY FOR THE PAYMENT OF ALL CHARGES RELATIVE TO THE PREPARATION, EXECUTION, AND REGISTRATION OF SUCH DOCUMENTS AS MAY BE REQUIRED BY THE CF OR ITS SOLICITORS. I HAVE NO OTHER APPLICATIONS PENDING WITH A CF ON MY OWN BEHALF, NOR ON BEHALF OF ANY AFFILIATED, CONTROLLED OR SUBSIDIARY COMPANY ASSOCIATED WITH ME, WHETHER BY DIRECT OR BENEFICIAL SHARE OWNERSHIP. BY SIGNING THIS APPLICATION, THE APPLICANT CONFIRMS THAT HE/SHE HAS MADE BEST EFFORTS TO ACCESS FUNDS FROM OTHER SOURCES. THIS IS MY EXPRESS WRITTEN CONSENT TO A PERSONAL INVESTIGATION. PER: ____________________ PER: _________________________ DATE: __________________ SIGNATURE WITNESS PER: ____________________ PER: _________________________ DATE: __________________ SIGNATURE WITNESS PER: ____________________ PER: _________________________ DATE: __________________ SIGNATURE WITNESS *IF PARTNERSHIP, EACH PARTNER MUST COMPLETE A SEPARATE LOAN APPLICATION* ................
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