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Southern Maine Planning and Development Commission Full Application394970203835Supporting information as necessary: Special Licenses / estimates / quotations /receipts / contracts / orders / invoices / sales agreements or documentation from architects, engineers, contractors, suppliers or others involved in the sale, lease, construction or renovationof fixed assets for the applicants project, including schedules of implementation / Security / Collateral Description: include most recent appraisal of real estate, machinery and equipment when applicable/ Debt Schedule / Aging of Accounts Payable & Accounts Receivable / Letters of Commitment from bank / agency / Copy of Lease / Deed.6) Personal Financial Statement: For any owner with 20% or Greater interest in business5)Debt Schedule: Attached Exhibit4)Interim Financial Statements: No more than 90 days prior to application3)Historical Financial Statements: Last three (3) years Business and personal tax returns2)Financing Application1)All relevant information must be received by staff before loan review will start. Please (X) if attached or (N/A) if not applicable:00Supporting information as necessary: Special Licenses / estimates / quotations /receipts / contracts / orders / invoices / sales agreements or documentation from architects, engineers, contractors, suppliers or others involved in the sale, lease, construction or renovationof fixed assets for the applicants project, including schedules of implementation / Security / Collateral Description: include most recent appraisal of real estate, machinery and equipment when applicable/ Debt Schedule / Aging of Accounts Payable & Accounts Receivable / Letters of Commitment from bank / agency / Copy of Lease / Deed.6) Personal Financial Statement: For any owner with 20% or Greater interest in business5)Debt Schedule: Attached Exhibit4)Interim Financial Statements: No more than 90 days prior to application3)Historical Financial Statements: Last three (3) years Business and personal tax returns2)Financing Application1)All relevant information must be received by staff before loan review will start. Please (X) if attached or (N/A) if not applicable:82423089535Please answer all questions thoroughly and completely to the best of your ability. Missing information will onlydelay the processing of your application. Only when a completed application and all materials referred to on the checklist are received will loan processing begin.00Please answer all questions thoroughly and completely to the best of your ability. Missing information will onlydelay the processing of your application. Only when a completed application and all materials referred to on the checklist are received will loan processing begin.475869011557000 Project ApplicantDate of Application Borrower's NameCell Phone Number513969010096500 Social Security Number133223010668000512064010668000Name of BusinessPhone Number133223010668000512064010668000AddressFederal Tax ID Number133223010668000512064010668000Address 2DUNS Number()133223010668000512064010668000City, State, Zip CodeContact Person133223010668000512064010668000Amount RequestedE-Mail Address478155029845009810753937000WebsiteNAICS #()Business Organization:330517514224000655320013271500480060014224000183832514224000S Corporation C Corporation Partnership Sole Proprietorship 26098502476500296862563500___00___Limited Liability Corporation __If Incorporated, list Date and State of Incorporation: Years in Business: Ownership / Management:Major Stockholders, Partner or Proprietors with 20% or greater interest:Name:Address:Ownership %:Date of Birth:Social Security #:Project Representatives:Contact Name:Phone Number:Regular Bank: Probable Lender:Legal Representative: Accountant: Disclosure Information:Has any individual above or your company received any government assistance (i.e., direct loans, guaranteed loans, grants) from Federal State or Local sources (SBA, USDA, EDA, CDBG, HUD, FAME etc.), including but not limited to any loans which were guaranteed by these sources? This includes any assistance which you personally guaranteed or in which you had any ownership in the borrower.YES: NO: If YES, please explain:Has any individual or company associated with any individual above, been involved with bankruptcy proceedings, insolvency, bank "work-out" forced or friendly liquidation and the disposition of those activities? YES: NO: If YES, please explain, listing parties involved:Has the company or any stockholder with 20% or greater investment in the company been convicted of any crime or had any judgment filed against them, currently or pending?YES: NO: If YES, please explain, giving details regarding results, judgments, or penalties:Does the company or any individual above have delinquent tax authority obligations (IRS, State Sales, Real Estate, Property, etc.) or liens or judgments that were the result of any of these or previous tax authority obligations?YES: NO: If YES, please explain:Project SummaryBrief Description of Business and History:Explain the impacts to your business due to the pandemic, and how the funds from this loan will aid in recovering some of these losses:Sources and Uses of Financing:i.Source of Funds:Name:Amount:Term:Rate:Private: Other Public: Other Source: Other Source: Equity: Total ii. Use of Proceeds:Description:Amount:Working Capital: Equipment Acquisition: Equipment Installation: Repairs/Renovations: Other Construction Costs Miscellaneous: Professional Fees: Other (Specify): 133223013081000278892013081000570420513081000133223010350500278892010350500570420510350500133223010350500278892010350500570420510350500Total: Employment:Number of Employees:Current: full-time: part-time: Number of jobs to be created: full-time: part-time: Current Annual Payroll: $ Confidentiality of Records:I (we) request that information provided by me (us) and developed by the lending agency, or its staff or agents, with respect to this application for financial assistance be designated Confidential and not open for public inspection. This includes the disclosure of tax or financial information; assessment of the creditworthiness or financial condition; records obtained by the lending agency in connection with the monitoring or servicing of an existing project; proprietary information; and information regarding investors, current and potential.Certifications:To the best of my (our) knowledge, the above information is accurate, true, and correct. I (We) understand that any false or misleading information I (we) provide may lead to my (our) disqualification from this program. I (we) authorize the lending agency and others on its' behalf to gather, collect and verify any and all information about me (us) furnished in connection with this application or which it believes is advisable and which relates to this application and loan. The information that may be verified includes, but is not limited to, the following: employment, pensions, mortgages, deposits, and any other income; personal or business loans; hazard insurance; and further, to obtain a credit report. If this application is approved, I (we) will be obligated by the promissory note I (we) will sign and the lending agency will send me (us). This application remains the lending agency's property, whether or not this application is approved.45720020891500395478020891500Applicant's SignatureCo-Applicant's Signature45720023812500395478023812500Applicant's Name / TitleCo-Applicant's Name / Title45720023812500395478023812500DateDateDEBT SCHEDULEBusiness obligations only, not personal loansAs of , 20(As of the date of most the recent financial statement)Original DateOriginal AmountMonthly PaymentInterest RatePresent BalanceMaturity DateCreditorCollateralUp to Date?Show estimates for new loans expected during the next 12 monthsPERSONAL FINANCIAL STATEMENTIMPORTANT: Read these directions before completing this statement.If you are applying for individual credit in your own name and are relying on your own income or assets and not the income or assets of another person as the basis for repayment of the credit requested, complete only Sections 1 and 3.If you are applying for joint credit with another person, complete all Sections providing information in Section 2 about the joint applicant.If you are applying for individual credit, but are relying on income from alimony, child support, or on the income or assets of another person as a basis for repayment of the credit requested, complete all Sections, providing information in Section 2 about the person whose alimony, support, or maintenance payments or income or assets you are relying on.If this statement relates to your guaranty of the indebtedness of other person(s), firm(s) or corporation(s), complete Sections 1 and 3.SECTION 1 – INDIVIDUAL INFORMATIONSECTION 2 – OTHER PARTY INFORMATIONNameNameResidence AddressResidence AddressCity, State & ZipCity, State & ZipPosition or OccupationPosition or OccupationBusiness NameBusiness NameBusiness AddressBusiness AddressCity, State & ZipCity, State & ZipRes. PhoneBus. PhoneRes. PhoneBus. PhoneE – MailE – MailSECTION 3 – STATEMENT OF PERSONAL FINANCIAL CONDITION AS OF, 201 PERSONAL ASSETSIn DollarsPERSONAL LIABILITIESIn Dollars(Do not include Assets of doubtful value)(Omit cents)(Omit cents)Cash on hand and in this bank$Notes Payable to banks – secured – See Sch. F$Cash in other banksNotes Payable to banks – unsecured – See Sch. FU.S. Govt. & Marketable Securities – See Sch. ADue to brokersAmounts payable to others – securedNon-Marketable Securities – See Schedule BAmounts payable to others – unsecuredSecurities held by broker in margin accountsAccounts and bills dueRestricted or control stocksUnpaid income taxPartial interest in Real Estate Equities –Other unpaid taxes and interestSee Schedule CReal estate mortgages payable – See Schedule DReal Estate Owned – See Schedule DOther debts – itemizeLoans ReceivableAutomobiles and other personal propertyCash Value – Life Insurance – See Schedule EOther assets – itemize – See Sch. G, if applicableTOTAL LIABILITIESNET WORTHTOTAL ASSETS$TOTAL LIABILITIES AND NET WORTH$SOURCES OF INCOME FOR YEAR ENDED:201 PERSONAL INFORMATION (Attach separate sheet if necessary)Salary bonuses & commissions$Do you have a will?If so, name of executor:DividendsReal estate incomeAre you a partner or officer in other venture(s)? If so, complete Sch. GOther income (Alimony, child support or separatemaintenance income need not be revealed if youAre you obligated to pay alimony, child support or separatewish not to have it considered as a basis formaintenance payments?If so, describe:repaying this obligation.)Are any assets pledged other than as described on schedules? If so,describe:TOTAL$CONTINGENT LIABILITIESIncome tax settled through (date)Do you have any contingent liabilities? If so, describe:Income tax settled through (year):Are you a defendant in any suits or legal actions? If so, describe.As endorser, co-maker or guarantor?$On leases or contracts?$Personal bank accounts carried at:Legal claims$Other special debt$Have you ever been declared bankrupt? If so, describe:Amount of contested income tax liens$SCHEDULE A – U. S. GOVERNMENT & MARKETABLE SECURITIESNumber of Shares or Face Value (Bonds)DescriptionIn Name OfAre These Pledged?Market ValueSCHEDULE B – NON-MARKETABLE SECURITIESNo. of SharesDescriptionIn Name OfPledged? Y/NSource of ValueValueSCHEDULE C – PARTIAL INTERESTS IN REAL ESTATE EQUITIES (Attach separate sheet if necessary)Address & Type of PropertyTitle In Name OfOwner- ship %Date AcquiredCostMarket ValueMonthly PaymentR. E. TaxesMortgage BalanceSCHEDULE D – REAL ESTATE OWNED (Attach separate sheet if necessary)Address & Type of PropertyTitle In Name OfDate AcquiredCostMarket ValueMonthly PaymentR. E. TaxesMortgage BalanceSCHEDULE E – LIFE INSURANCE CARRIED, INCLUDING N.S.L.I. AND GROUP INSURANCEName of Insurance CompanyOwner of PolicyBeneficiaryFace AmountPolicy LoansCash ValueSCHEDULE F – BANKS OR FINANCE COMPANIES WHERE CREDIT HAS BEEN OBTAINEDName & Address of LenderCredit In The Name OfOriginal DateHigh CreditCurrent BalanceSecured or UnsecuredMonthly PaymentSCHEDULE G – BUSINESS VENTURESName & Address Of Business VentureTotal Assets Listed In Section 3Ownership PercentagePosition/Title in the BusinessTotal Assets Of BusinessLine of BusinessYears In BusinessThe information contained in this statement is provided for the purpose of obtaining or maintaining credit with you on behalf of the undersigned, or persons, firms or corporations in whose behalf the undersigned may either severally or jointly with others, execute a guaranty in your favor. Each undersigned understands you are relying on the information provided herein (including the designation made as to ownership of property) in deciding to grant or continue credit. Each undersigned represents and warrants that the information provided is true and complete and that you may consider this statement as continuing to be true and correct until a written notice of a change is given to you by the undersigned. You are authorized to make all inquiries you deem necessary to verify the accuracy of the statements made herein and to determine my/our credit worthiness. You are authorized to answer questions about your credit experience with me/us.Signature (Individual) _ Date Signed S. S. No. Date of Birth Signature (Other Party) Date Signed S. S. No. Date of Birth ................
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