KSBCI 2.0 Lender Enrollment Form

KSBCI 2.0 Lender Enrollment Form
Lender Information
Name of Financial Institution (Lender)
ABA#
Lender Regulatory ID (FDIC, CDFI, NCUA, etc.)
Lender Type

CDFI bank, thrift, credit union, or depository institution holding companyNon-CDFI community bankOther bank, thrift, or depository institution holding companyCDFI loan fundNon-CDFI credit union
Is the Lender a Minority Depository Institution?

YesNo
Lender Representative

First NameLast Name
Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Extension (if applicable)
Email
example@example.com
The KSBCI 2.0 program uses demographic information from borrowers to qualify them for enhanced incentives, per U.S. Department of Treasury guidelines. Does the Lender agree to invite applicant borrowers to complete a demographic survey? (Note: Demographic information is voluntary and borrowers may choose to “prefer not to respond.)

YesNo
Contact Person for Lending Institution
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Extension (if applicable)
Email
example@example.com
Display this contact person online?

YesNo
KSBCI 2.0 Requirements
Please check the Kentucky Small Business Credit Initiative 2.0 (KSBCI 2.0) Program(s) in which you are requesting enrollment:

Kentucky Collateral Support ProgramKentucky Loan Participation Program
Please attach the following in the upload section below:
- Lender’s Plan to determine the amount of KSBCI 2.0 assistance per borrower based on borrower’s credit profile (view our example provided here);
- KSBCI 2.0 Lender Eligibility Certification;
- Lender’s Marketing Plan or other evidence of marketing to underserved business populations; and
- Lender locations in which program(s) will be offered.
Cancelof
Certification of Application
Eligibility for financial assistance is determined by the information presented in this application and in the required attachments.

I, the undersigned, on behalf of the Lender, hereby represent and certify that the foregoing application information, including all attachments, to the best of my knowledge, is true, complete and accurate. Any changes in the application facts and representations presented herein by the Lender, including but not limited to the application and the attachments will be reported to the staff of the Kentucky Economic Development Finance Authority.

The undersigned has complied with all federal statutes relating to non-discrimination including, but not limited to, Title VI of the Civil Rights Act of 1974, which prohibits discrimination on the basis of race, color, or national origin. The undersigned has either adopted its own Title VI Implementation Plan, which will be made available for review by the Cabinet’s Title VI Coordinator, or agrees to adopt the Title VI Implementation Plan of the CED.
Authorized Signature
For Electronic Signature: The person responsible for signing the document may type his/her name in the signature field, but the name must be preceded by a “/s” (e.g., /s Jim Smith).
Printed Authorized Name and Title
Title
Date

MonthDayYear
Date
Should be Empty:

KSBCI 2.0 Lender Enrollment Form

Lender Information

Contact Person for Lending Institution

KSBCI 2.0 Requirements

Certification of Application