Hoosier Equipment Lease Purchase Program Application

Government Entity Name*
Contact Name*

First NameLast Name
Contact Title
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
Phone Number

Area CodePhone Number
Were you referred to the HELP program by another unit of government?

YesNo
If so, who referred you?

Equipment Information
Equipment Description (year, make, model)
What Essential Function does the Proposed Equipment Perform?

Financing Information
1) Equipment Cost
2) Down Payment Amount
3) Trade-in Amount
4) Amount Requested*
5) Estimated Delivery Date*

MonthDayYear
Date
6) Financing Term*
7) Payment Frequency*

AnnualSemi-AnnualQuarterlyMonthly
8) First Lease Payment Date*

MonthDayYear
Date
9) Preferred Closing Date*

MonthDayYear
Date
10) Name of fund used to pay for equipment*
11) Cash Balance of Fund used to Pay for the Equipment