IMPACT LOAN FUND Financing Application

Financing Application
A. BUSINESS INFORMATION
1. Name of Business
2. Business Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
3. Name of Primary Contact at Business

First Name Last Name
4. Phone Number of Primary Contact
5. E-mail Address of Primary Contact
example@example.com
6. Legal Structure of Business

Sole Proprietor Partnership Corporation LLC Other
7. Date of Business Formation (leave this blank if you are a Sole Proprietor)

Month Day Year
Date
8. Federal Tax Identification Number (or Social Security Number if you are a Sole Proprietor)

9. Ownership Information: If your business has more than one owner, please provide the name of each owner and their percentage share of ownership. If you are the ONLY owner of your business, please skip this item and proceed to #10.

	Name of Owner	Percent Ownership
Owner 1
Owner 2
Owner 3
Owner 4

10. Number of Employees: Please fill out the information requested in the table below about the number of employees in your business.

	Full-Time	Part-Time
Existing Number of Employees
Employees to be Added in the Next 3 Years

Financing Application
If there is a separate borrowing company involved in your financing application, please fill out the information requested below. If there is NOT a separate borrowing company involved, proceed to the next section.

B. BORROWING COMPANY INFORMATION
1. Name of Borrowing Company
2. Address of Borrowing Company

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
3. Legal Structure of Borrowing Company

Sole Proprietor Partnership Corporation LLC Other
4. Date of Borrowing Company Formation

Month Day Year
Date
5. Federal Tax Identification Number (FEIN) or Social Security Number

Financing Application
C. FINANCING REQUEST
1. What is the amount of the loan you would like to receive?
2. What products and/or services does your business provide?
3. What will you use the loan for? Check all that apply.

A real estate development project Purchase or lease of equipment Fit-out of tenant/rental space Working capital/inventory Other
4. For Real Estate Development Projects Only: If you are seeking financing for a real estate project, please provide the address of the property. If you are NOT seeking financing for a real estate project, proceed to the next section.

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Financing Application
E. CERTIFICATION, AUTHORIZATION & SIGNATURE.

The information provided in this application is confidential and will only be viewd by Impact Loan Fund staff.
The information I have provided in this application is accurate and true.

Yes
Signature

Clear
Should be Empty:

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