SMALL BUSINESS LOAN APPLICATION

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1 SMALL BUSINESS LOAN APPLICATION APPLICANT/BUSINESS INFORMATION How did you hear about us *: Have you ever had a loan with us * : Yes No Business Name * City * State * County * Zip * Mailing Address (if different): Main Phone * Cell Phone * Fax * EIN/TIN * *: Website Business Structure: C Corporation S Corporation Sole Proprietorship Partnership LLC Date Business was registered, incorporated or purchased: MWBE certification *: [ ] business is not certified [ ] business is certified by these entities: Description of the Business *: Years of Experience in this field *: Average Month Sales * $ Highest Month Sales * $ Lowest Month Sales * $ Number of employees (incl. yourself) * : How many jobs do you anticipate to create as a result of this loan *:

2 How many jobs would be lost if you did not get this loan *: Is your business seasonal * : Yes No Where does the business get its raw materials or supplies *: How do you pay for them *: [ ] Credit [ ] Cash [ ] net 30/60/90 [ ] Other (explain) Business Location *: Home Storefront Market Street Vendor Other Time at Current Location *: Years: Months: Do you *: [ ] Own [ ] Rent If renting: Landlord s Name * : Landlord s Address: City: State: County: Zip: Landlord s Phone: Fax Number: LOAN INFORMATION Loan Amount Requested *: Requested Term (repayment period) *: months Approximate monthly payment you would feel comfortable with *: Use(s) for Loan Funds Requested (please list individually) *: Cost *: :

3 What is the minimum loan amount you can work with and what will the uses be *: Use(s) for Loan Funds (please list individually) *: Cost *: : BUSINESS FINANCIAL INFORMATION Owner Equity: dollar amount of equity that principal/owner(s) have invested in the business to date: $ Business Assets: (Materials, Inventory, Machinery, Accounts Receivable, Furniture, Fixtures, Vehicles) Item Value * $ Own Free and Clear * Y N Item Value * $ Own Free and Clear * Y N Business Liabilities: (all business debts including credit cards, loans lines of credits etc) Item Mthly Payment Amount * $ Owed to * Balance * $ Item Mthly Payment Amount * $ Owed to * Balance * $ Collateral: What collateral will be used to secure this loan? Item Resale Value * $ Own Free and Clear *? Y N Item Resale Value * $ Own Free and Clear *? Y N Monthly Business Financials * Reporting * : Actual Projected (only if startup) Business Income (monthly): Gross Sales *: $ Other income : $ _

4 Business Expenses (monthly): Cost of Goods Sold (raw materials, merchandise, inventory) * $ Business rent/mortgage * $ Salaries/Labor * $ Utilities * $ Insurance, Gas, Misc. * $ Vehicle and other loan payments * $ Credit Card payments * $ Other $ _ Net _ Professional References * Reference 1: Name * City * State * Zip * County * Contact Phone * Work Phone * Relationship * Reference 2: Name * City * State * Zip * County * Contact Phone * Work Phone * Relationship *

5 PRINCIPAL/OWNER INFORMATION First Name * Last Name * City * State * County * Zip * Home Phone * Work Phone * Social Security # * Driver s License # * Date of Birth * Names Credit can be under * Time at Current Residence * Years Months Do you * [ ] Own [ ] Rent If renting: Landlord s Name * Landlord s City * State * County * Zip * Landlord s Phone * Fax Number: Previous Address (if less than a year): Do you have a bank account? * [ ] Yes [ ] No If yes * [ ] Personal [ ] Business [ ] Both Percentage of business ownership * PRINCIPAL/OWNER FINANCIAL INFORMATION Monthly Personal Financials * (please provide your information only, not household): Personal Income (monthly) : Take home from business * $ Employment income * $ Other income: $ _

6 Personal Expenses (monthly) : Education and childcare * $ Food and clothing *: $ Child support/alimony * $ Home rent/mortgage * $ Utilities * $ Insurance, Gas, Misc. * $ Credit Cards Payments * $ Vehicle and Other Loan payments * $ Other $ _ Employment Information * : Are you Employed *? [ ] Yes [ ] No (if no, please explain: Employer s Name * Contact Person * City * State* Zip * Phone Number * Fax Number: Income/month (approx.) * Time at current employer * Credit Information *: Have you ever filed for bankruptcy * [ ] Yes [ ] No Are you in arrears in child support payments * [ ] Yes [ ] No Are you currently late on any mortgage and/or vehicle payments? * [ ] Yes [ ] No Have you recently applied for a business loan to a bank? * [ ] Yes [ ] No if yes: what was the outcome? *

7 Socio-Economic Information: Years of education: Marital Status: TANF recipient? [ ] Yes [ ] No [ ] Don t Know Number in household (including self) * Annual Household Income (AGI from most recent Federal Tax Return) * $ Race: [ ] Black/African American [ ] Asian [ ] Hispanic [ ] Pacific Islander [ ] White [ ] Native American [ ] Other: Ethnic Group: [ ] Hispanic [ ] Non-Hispanic [ ]Other Veteran Status: [ ] Non-Vet [ ] VN-era Vet [ ] Other Vet Are you disabled: [ ] Yes [ ] No Are there any additional principal/owners? [ ] Yes [ ] No Will there be a co-borrower: [ ] Yes [ ] No PLEASE READ AND SIGN BELOW By clicking on submit, I attest that all of the information on this application is true. I authorize Community Capital New York to investigate and verify the above information, and contact any references regarding this application. I also authorize Community Capital New York to perform a credit check, which may include obtaining consumer and/or commercial credit reports and to exchange information about credit experience with other creditors from time to time, as authorized by law. The release of all information by Community Capital New York, in any manner is hereby authorized whether such information is of record or not and I hereby release all persons, agencies, firms, companies etc., from any damages resulting from such information. I understand that Community Capital New York will retain this application whether the loan is approved or denied and that I can appeal Community Capital New York s decision if the loan is denied.

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