APPLICATION. for. Deferral of Loan Repayments (NSW RAA Loans only) SMALL BUSINESS CHECK LIST

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1 APPLICATION for Deferral of Loan Repayments (NSW RAA Loans only) SMALL BUSINESS CHECK LIST To avoid any delay in the processing of your application, please complete the following checklist. Have you included: The last 3 years balance sheets and Financial Statements of your business enterprise. (These include Profit and Loss Statements, Trading account & Depreciation schedules) The last 3 years individual Taxation Returns and a current listing of all Assets & Liabilities held by each: Individual Director(s)/Shareholder(s) of all companies. Individual members of partnerships/firm & Family Trusts (Note: In each of the above, each Director/Shareholder etc. is to provide details including source of income, if they are not primarily dependent on the business for their livelihood). Monthly Cash Flow Budget for next 12 months. Have all questions been answered? Is all financial information completed as required? Have all parties (applicants) to the request signed the declaration? NSW Rural Assistance Authority 1 V: /13

2 Your NSW Rural Assistance Authority Reference Number BP: 1. NAME OF EXISTING BORROWER:- (Company, firm, partnership or individual etc.) Trading Name ABN Contact Numbers Phone Mobile Fax Postal Address Postcode Have you had previous discussions with NSW RAA staff regarding deferment of loan repayments? If so, what is the name of the officer? Briefly describe the reason for your request to defer NSW RAA repayments. NSW Rural Assistance Authority 2 V: /13

3 Do you propose to increase your bank overdraft or loan facilities during the period of this deferment? If so, please discuss with NSW RAA staff as increased borrowings may require NSW RAA consent to an increase in priority in respect to the bank s mortgage. What arrangements have you made with your bank or finance company regarding repayments? Details of NSW RAA Loans Loan Contract No. Instalment Amount Due Date of Instal. Current Arrears (if any) Deferment Required to (Date) Remarks 2. BUSINESS DETAILS Do you own the business? Yes / No How long have you been the proprietor of the business? Years What was the purchase price? Break up - Goodwill Stock Plant & equipment RENTED PREMISES If your business premises are rented or leased please answer the following: 1. Rent or lease payment (Weekly, Monthly, Annually) delete as applicable 2. Original term of lease? Years remaining on lease? 3. Is a written lease in existence? Yes / No If NO what are the lease arrangements? 4. Who is in possession of the written lease? NSW Rural Assistance Authority 3 V: /13

4 Please provide an age listing of all your creditors and debtors NSW Rural Assistance Authority 4 V: /13

5 3. MONTHLY CASH FLOW (Your own computerised schedule is preferable) Year ending / / (Cash flow for the next 12 months from the date of the application. Show amounts to the nearest 000 eg 1, ) INCOME 000 Cash Sales Trade Debtors Other Total Cash Inflow (Income) TOTALS EXPENDITURE 000 Trade Creditors Salaries & Wages Stock Purchases Operating Expenses Interest Lease Rentals Personal Drawings Total Cash Outflows (Expense) Loan Repayment Hire Purchase Repayment Lease Repayments Net Cash Movements Opening Bank Balance Closing Bank Balance NSW Rural Assistance Authority 5 V: /13

6 4. DETAILS OF ALL BORROWINGS PLEASE USE WHOLE DOLLAR AMOUNTS ONLY PART A Enter information on Overdraft, Term Loans, Fixed Rate Loans, Commercial Bill facilities, Investment Loans or Family Loans or Private Loan Facilities, Credit Cards etc. (Indicate if interest is a V Variable or F Fixed in the appropriate column). (** Indicate:- [M] monthly, [H] half yearly, [A] annually) Financier Type Term in Years Limit Balance Owing (Dr/Cr) Interest Rate V or F Instalment ** Due Expiry / Review Date TOTALS PART B Lease Arrangements Lease Company Contract Amount Term in Years Balance Owing Interest Rate Instalment ** Due Residual Value Due Date TOTALS PART C Hire Purchase Arrangements Finance Company Term in Years Balance Owing Interest Rate Instalment ** Due Expiry Date TOTALS PART D Total the Balance Owing and Annual Instalment columns from parts A, B & C and enter the amounts into the table below. This will show the total amount you owe and your annual commitment. PART A PART B PART C TOTAL TOTAL TOTAL FINAL TOTAL Balance Owing Annual Instalments NSW Rural Assistance Authority 6 V: /13

7 5. STATEMENT OF ASSETS & LIABILITIES ASSETS Real Estate Business Premises Other Business - Stock Business - Plant & Equipment Business - Fixtures & Fittings Goodwill Motor Vehicles Cash at Bank Investments Other Assets (List) Trade Debtors TOTAL ASSETS LIABILITIES Annual Commitments Total Balance Owing (from previous page) Stock Firm/Chemical Co. Rates Crown Instalments Other Current Accounts (List those above 1000) TOTAL LIABILITIES NET ASSETS (Total Assets less Total Liabilities) NSW Rural Assistance Authority 7 V: /13

8 6. STATEMENTS GENERAL STATEMENT Any person who knowingly and with intent to defraud the NSW Rural Assistance Authority or another person, files an application for assistance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent act, which is a crime under the Crimes Act 1900 and subjects the person to criminal penalties. PRIVACY The information in this application is provided voluntarily and is being collected by the NSW Rural Assistance Authority for purposes related to the administration of the scheme of assistance under which you have applied, including the assessment of the effectiveness of the scheme. This may involve disclosing the information in this application to contractors engaged by the Authority or to either State or Commonwealth government agencies. We will supply you with details of those that we have disclosed information to, if you apply to us in writing. Information regarding your application may also be discussed and exchanged with the nominated contact persons listed by you in your application. Not providing the information requested in this application or providing false or misleading or incomplete information may impact on the ability of the Authority to accurately assess your application. The NSW Rural Assistance Authority agrees to take all reasonable measures to ensure that the personal information collected by it is stored securely. You may access or correct your personal information by contacting the Authority by telephone on (toll free) (Calls to 1800 numbers from your home phone are free. Calls from a public phone and mobiles may be timed and attract charges.) or by writing to: Manager Administration, NSW Rural Assistance Authority, Locked Bag 23, ORANGE, NSW, CONTACT DETAILS Solicitor s Details Firm Name: Contact Name: Phone: Mobile: Fax: Accountant s Details Firm Name: Contact Name: Phone: Mobile: Fax: Financier s Details Bank or Company Name: Contact Name: Phone: Mobile: Fax: Rural Counsellor s Details Counselling Service Name: Contact Name: Phone: Mobile: Fax: 8. DECLARATION I/We hereby give approval to the NSW Rural Assistance Authority to obtain and provide information relevant to this application from my/our banker(s), accountant or any other nominated person. I/We solemnly declare that this is a true and correct statement of all my/our affairs and I/We make this solemn declaration subject to punishment by law provided for any wilful false statement Signed Applicant: Applicant: Date: / / Date: / / Signed Applicant: Applicant: Date: / / Date: / / NSW Rural Assistance Authority 8 V: /13

9 Completed Requests should be returned to: NSW Rural Assistance Authority Locked Bag 23, ORANGE NSW 2800 Contact details: 161 Kite Street, ORANGE NSW 2800 Telephone Freecall Calls to 1800 numbers from your home phone are free. Calls from a public phone and mobiles may be timed and attract charges. Facsimile If you have difficulty understanding this form you should seek the assistance of your rural/financial counsellor, solicitor, accountant or a trusted family member/friend. NSW Rural Assistance Authority 9 V: /13

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