LOUIS DIMARIA BUSINESS FUNDING APPLICATION

Louis DiMaria Office: (516)431-3100 - Ext. 126 Cell: 516)454-1001 Email: Louis@SouthShoreFunding.net

Please fill in all required fields and any additional fields that pertain to your application
Today's Date*

MonthDayYear
Date
Entity Type*

CorpSole PropLLCPartnership
Name of Business (doing business as)*
Type of Business
Business Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Start Date*

MonthDayYear
Date
Business Phone Number
BusinessTax ID #*
Website
Email Address*
example@example.com
BUSINESS OWNER #1

If Ownership is less than 100% please complete information for other business owners as well
Ownership %*
Name:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
FICO Score*
Home Phone
Cell Phone*
Email Address*
example@example.com
Social Security Number*
Date of Birth*

MonthDayYear
Date
Driver's License State
Driver's License #
BUSINESS OWNER #2

To be filled out by any partner that has 25% or more ownership
Ownership %
Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
FICO Score
Home Phone
Cell Phone
Email Address
example@example.com
Social Security Number
Date of Birth

MonthDayYear
Date
Driver's License State
Driver's License Number
To Help Us Serve You Better, Please Answer All Questions. Thank you!
Business Location*

StorefrontHomeWebsite-Remote
Gross Annual Sales $*
Visa/MC Sales Per Month $
Credit Card Processor
Has The Business Ever Filed For Bankruptcy?*
Type yes or no
Year Filed
Does The Business Have Tax Liens?*
Amount of Tax Lien $
Is There A Payment Plan?
Start Date?

YearMonthDay
Date
Number Of Businesses Owned
Does The Business*

OwnLease
Time Left On Lease:
Monthly Amount Of Lease/Mortgage: $
Landlord/Mortgage Co Name:
Landlord/ Mortgage Company Contact Number:
Please enter a valid phone number.
Business Banking Name:
Bank Branch City and State
Bank Contact Name
Bank Contact Phone Number:
Please enter a valid phone number.
Is The Business Seeking Funding From Other Lenders?
Type Yes or No
If Yes, Who?
Would You Want to Use Real Estate as Collateral to Get a Better Rate?
If Yes, Property Type
Type Commercial, Residential, Multi-use etc to describe property type
Do You Have Existing Cash Advances?
Type yes or no.
Cash Advance Company Name:
Initial Funding Amount $
Date Funding Received

YearMonthDay
Date
Current Balance $
Payment Frequency
Cash Advance Company Name:
Initial Funding Amount $
Date Funding Received

YearMonthDay
Date
Current Balance $
Payment Frequency
Cash Advance Company Name:
Initial Funding Amount $
Date Funding Received

YearMonthDay
Date
Current Balance $
Payment Frequency
By signing below, each of the above listed business and business owner/officer (individually and collectively, "you") authorize LDPSU Corp, DBA South Shore Funding. and each of its representatives, successors, assigns and designees ("Recipients") that may be involved with or acquire commercial loans having daily repayment features or purchases of future receivables including Merchant Cash Advance transactions, including without limitation the application therefor (collectively, "Transactions") to obtain consumer and/or personal, business and investigative reports and other information about you, including credit card processor statements and bank statements, from one or more consumer reporting agencies, such as TransUnion, Experian and Equifax, and from other credit bureaus, banks, creditors and other third parties. You also authorize LDPSU Corp, dba South Shore Funding to transmit this application form, with any of the foregoing information obtained in connection with this application, to any or all of the Recipients for the foregoing purposes. You also consent to the release, by any creditor or financial institution, of any information relating to any of you, to LDPSU Corp, dba South Shore Funding. and to each of the Recipients, on its own behalf

Amount Requested: $ Signature (1):
Signature (1)*

Clear
Date*

MonthDayYear
Date
Signature (2)

Clear
BUSINESS PURPOSE
To Expedite Your Application Please Upload your 4 Most Recent Business Bank Statements, Copy Of ID and Voided Check:

Cancelof
Should be Empty:

BUSINESS OWNER #1

BUSINESS OWNER #2

BUSINESS PURPOSE