IMPACT LOAN FUND Financing Application

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

Street Address

Street Address Line 2

CityState / Province

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

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

Sole ProprietorPartnershipCorporationLLCOther
7. Date of Business Formation (leave this blank if you are a Sole Proprietor)

MonthDayYear
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

CityState / Province

Postal / Zip Code
3. Legal Structure of Borrowing Company

Sole ProprietorPartnershipCorporationLLCOther
4. Date of Borrowing Company Formation

MonthDayYear
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 projectPurchase or lease of equipmentFit-out of tenant/rental spaceWorking capital/inventoryOther
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

CityState / Province

Postal / Zip Code

1. Please describe your current or intended business location. Square footage? Property charcateristics? Why is this location good for your business?
2. Please provide a general background on the business. What is your experince in the field? How does your company generate revenue?
3. Who are your primary customers? How do they find out about you? Do you offer payment terms to your customers? If so what percentage do not pay upon reciving the good or service?
4. Please describe any key changes in the business. Revenues, Expenses, and profits over the past 3 years. What factors will influence your operations going forward?
5. If you will hire new employees in the next 24 months because of this loan what positions will be created and when do you expect to hire them?
6. Please provide any additional information regarding the business that will assist in underwriting the loan request.

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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