EXHIBIT C MISSISSIPPI DEVELOPMENT AUTHORITY SMALL BUSINESS LOAN GUARANTY PROGRAM APPLICATION
MISSISSIPPI DEVELOPMENT AUTHORITY APPLICATION FOR SMALL BUSINESS LOAN GUARANTY PROGRAM INSTRUCTIONS TO LENDER: LOAN APPLICANT WILL COMPLETE PART A. LENDER WILL COMPLETE PART B. PART A- LOAN APPLICANT INFORMATION 1. Applicant s Name 2. Co-Applicant s Name 3. Applicant s Telephone No. 4. Applicant s Address 5. Applicant s 9 Digit SSN or TAX ID No. 6. Applicant s Birth Date 7. Co-Applicant s Birth Date 8. Co-Applicant s 9 Digit SSN 9. Number of Employees: 10. Type of Individual Partnership Trust Joint Operation Operation Corporation Cooperative L.L.C. O Other (Explain) 11. Acres Owned 12. Acres Rented 13. Marital Status: Married Separated Unmarried (Including Single, Divorced, and Widowed) 14. Will applicant obtain and maintain required insurance coverage for outstanding balance as required by lender? Yes No 15. Has applicant satisfied underwriting criteria established by the lender related to loans? 16. Have you or any member of the entity ever been in receivership, been discharged in bankruptcy, or filed a petition for bankruptcy? 17. If Yes to Item 16 provide details: 18. Are you or any member of the entity delinquent on any debt to the State of MS or the Federal Government? 19. Are you (or members holding a majority interest if an entity applicant) a United States citizen? 20. APPLICANT S SIGNATURE 21. DATE 22. CO-APPLICANT S SIGNATURE 23. DATE
PART B ASSISTANCE REQUESTED 24. Interest Rate % Fixed Variable 26. Subsequent Loan In Same Operating Cycle 27. Repayment Terms 25. Repayment Period (Years) YES FUNDS PURPOSE NO 28. PURPOSES FOR WHICH FUNDS WILL BE USED 29. AMOUNT PROPOSED SECURITY 30. ITEM DESCRIPTION 31. LIEN POSITION 32. ESTIMATED VALUE 33. AMOUNT OF PRIOR LIEN 34. COLLATERAL VALUE LENDER INFORMATION AND CERTIFICATION 35. Lending Institution Name And Address TOTALS: 36. Lender 9 Digit Tax ID No./Employer ID No. 37. Regulatory Agency Telephone No.:
38. LENDER CERTIFIES THAT: a. It would not make the loan without the guarantee. b. The cash flow projection demonstrates that the proposed loan is sound and within the applicant s repayment ability. c. The proposed collateral securing the loan is considered adequate. d. In connection with subsequent loans made the loan applicant is in compliance with all loan agreements and all applicable certifications made are still valid. e. Lender has approved this loan. Subject to SBLGP being approved by MDA. Narrative and completed loan package that has been approved by lender Balance sheet dated Cash flow budget Description of the location of land improvement and equipment of applicant Borrower information (name, address, social security or tax identification number, percent ownership, balance sheet for each member) Credit report Plan for servicing borrower Proposed loan agreement Verification of all debts greater than 1,000 Verification of income 3 year financial history (income, expenses, balance sheets) SBLGP settlement sheet, executed by lender, with copy fully executed SBLGP settlement statement to be furnished to MDA upon closing of SBLGP along with copies of all executed closing documents. Additional loans as a result of this guaranty Enclosed attachments A and B 39. NAME OF LENDER S REPRESENTATIVE 40. TITLE OF LENDER S REPRESENTATIVE 41. AUTHORIZED LENDER REPRESENTATIVE S SIGNATURE 42. DATE
ATTACHMENT A BORROWER CERTIFICATION FOR USE OF LOAN PROCEEDS Legal Name of Small Business Loan Recipient: ( Borrower ) The Borrower hereby certifies to the [financial institution lender] the following: 1. The loan proceeds will be used for a business purpose. Business purpose includes, but is limited to, startup costs, working capital, business procurement, franchise fees, equipment, inventory, as well as the purchase, construction renovation or tenant improvements of an eligible place of business that is not for passive real estate investment purposes. The definition of business purpose excludes: activities that relate to acquiring or holding passive investments, such as commercial real estate ownership and the purchase of securities; and lobbying activities, as defined in Section 3(7) of the Lobbying Disclosure Act of 1995, P.L. 104-65, as amended. 2. The loan proceeds will not be used to: a. repay a delinquent federal or state income taxes unless the Borrower has a payment plan in place with the relevant taxing authority; or b. repay taxes held in trust or escrow, e.g. payroll or sales taxes; or c. reimburse funds owed to any owner, including any equity injection or injection of capital for the business continuance; or d. to purchase any portion of the ownership interest of any owner of the business. 3. The Borrower is not: a. an executive officer, director, or principal shareholder of the financial institution lender; or b. a member of the immediate family of an executive officer, director, or principal shareholder of the financial institution lenders; or c. a related interest of an such executive officer, director, principal shareholder, or member of the immediate family. For the purposes of these three borrower restrictions, the terms executive officer, director, principal shareholder, immediate family, and related interest refer to the same relationship to a financial institution lender as the relationship described in part 215 of title 12 of the Code of Federal Regulations, or any successor to such part.
4. The Borrower is not: a. a business engaged in speculative activities that develop profits from fluctuations in price rather than through normal course of trade, such as wildcatting for oil and dealing in commodities futures, unless those activities are incidental to the regular activities of the business and part of a legitimate risk management strategy to guard against price fluctuations related to the regular activities of the business; or b. a business that earns more than half of its annual net revenue from lending activities; unless the business is a non-bank or non-bank holding company Community Development Financial Institutions; or c. a business engaged in pyramid sales, where a participant's primary incentive is based on the sales made by an ever-increasing number of participants; or d. a business engaged in activities that are prohibited by federal law or applicable law in the jurisdiction where the business is located or conducted. (Included in these activities is the production, servicing, or distribution of otherwise legal products that are to be used in connection with an illegal activity, such as selling drug paraphernalia or operating a motel that knowingly permits illegal prostitution); or e. a business engaged in gambling enterprises, unless the business earns less than 33% of its annual net revenue from lottery sales. 5. No principal of the borrowing entity has been convicted of a sex offense against a minor (as such terms are defined in section 111 of the Sex Offender Registration and Notification Act (42 U.S.C. 16911)). For the purposes of this certification, principals is defined as if a sole proprietorship, the proprietor; if a partnership, each managing partner and each partner who is a natural person and holds a 20% or more ownership interest in the partnership; and if a corporation, limited liability company, association or a development company, each director, each of the five most highly compensated executives or officers of the entity, and each natural person who is a direct or indirect holder of 20% or more of the ownership stock or stock equivalent of the entity. Legal Name: By: Authorized Signatory Name: Title: Date:
ATTACHMENT B LENDER CERTIFICATION FOR USE OF LOAN PROCEEDS Legal Name of Financial Institution Lender: ( Lender ) The Lender hereby certifies to the Participating State the following: 1. The loan has not been made in order to place under the protection of the approved state program prior debt that is not covered under the approved state program and that is or was owed by the borrower to the financial institution lender or to an affiliate of the financial institution lender. 2. The loan is not a refinancing of a loan previously made to that borrower by the financial institution lender or an affiliate of the financial institution lender. 3. No principal of the financial institution lender has been convicted of a sex offense against a minor (as such terms are defined in section 111 of the Sex Offender Registration and Notification Act (42 U.S.C. 16911)). For the purposes of this certification, principals is defined as if a sole proprietorship, the proprietor; if a partnership, each partner; if a corporation, limited liability company, association or a development company, each director, each of the five most highly compensated executives, officers, or employees of the entity, and each direct or indirect holder of 20% or more of the ownership stock or stock equivalent of the entity Legal Name: By: Authorized Signatory Name: Title: Date:
ATTACHMENT C MISSISSIPPI DEVELOPMENT AUTHORITY SMALL BUSINESS LOAN GUARANTY PROGRAM SETTLEMENT SHEET Please complete this form and have the borrower to sign at closing. Please return to the Mississippi Development Authority, Financial Resources Division, Post Office Box 849, Jackson, Mississippi 39205. Project Name: Loan Number: Qualified Lender: SOURCES OF FUNDING: Lender Total Project Cost: SBLGP LOAN FEES: Origination Attorney Small Business Loan Other Guaranty Fee 1% Other TOTAL JOB IMPACT: Existing Jobs Jobs Created Total Jobs Business Owner: Majority Ethnic Minority Female Signature of Qualified Lender Director DATE: Signature of Borrower DATE: