Bridgehead Funding Application

Law Firm Information
Law Firm Entity Type *
Law Firm Entity Formation *

MonthDayYear
Date
State of Formation*
Number of Partners*
Number of Associates*
Number of Non-Lawyers*
Monthly Fixed Operating Costs (wages, insurance, rent etc)*
Estimated average monthly costs
What case management software does the firm use?*
Approximate Number of Filed Cases*
Approximate Number of Unfiled Cases*
Estimated Annual Revenue*
Next 12 Months

Disclosures
Please list all outstanding debt obligations owed by the firm. Please identify the associated lender as well as the balance.*
Are all partners of the firm active and in good standing with the governing State Bar?*
Have any of the partners ever had disciplinary actions brought by any State Bar association or other governing or regulatory agency?*
Has the firm or any of its partners ever filed for bankruptcy or insolvency?*
Has the firm or any of its partners had any judgments issued against them?*
Is the firm or any of its partners involved in any pending or threatened litigation?*
Does the firm or any of its partners have any unsatisfied tax liens?*
Is any partner of the firm involved with or a member of any other law firm or legal entity other than the one listed above? *
Has the firm or any of itsmembers had any previous foreclosures?*
How did you hear about us?*

Credit Report Authorization

Soft Pull - no impact to your credit report
Name*

First NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth*

MonthDayYear
Date
Social Security Number*
Secure Submission
Mobile Phone Number*
Please enter a valid phone number.
The undersigned authorizes Bridgehead Financial to procure a consumer credit report. In connection with this request, I authorize all credit agencies to release information they may have about the individual listed above, to the person or company with which this statement has been filed or their agents. This authorization, in original or copy form, shall be valid for this and any future reports or updates that may be requested.

I understand that I have the right to request additional disclosure as to the nature and scope of the credit review, upon written request, within a reasonable period of time. Bridgehead Financial may rely upon the information contained in this application in all respects.

Signature Page
I have reviewed all of the information submitted with this application and confirm that it is accurate and complete to the best of my knowledge. I will promptly notify Bridgehead Financial, LLC of any material changes to the information submitted herein.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

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Loan Application