COMMUNITY CAPITAL FUND
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- Angela Thomas
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1 COMMUNITY CAPITAL FUND FIRM NAME ADDRESS APPLICATION DATE CONTACT PERSON TELEPHONE PRINCIPALS DATE OF % OF CITIZENSHIP OR NAME/TITLE HOME ADDRESS S.S. # BIRTH OWNERSHIP TYPE OF VISA TYPE OF BUSINESS SIC CODE DATE FIRM ANNUAL GROSS MANUF RETAIL SERVICE WHSLE ESTABLISHED SALARY FEDERAL TAX I.D. PRINCIPAL PRODUCT/ FORM OF OWNERSHIP SERVICE SOLE PROP PARTNERSHIP CORP. STATUS OF BUSINESS PROJECT PURPOSE WORKING CAPITAL EMPLOYMENT: EXISTING NEW CONSTR. CAPITAL EQUIPMENT*# CURRENTLY EMPLOYED NEW RENOVATION INVENTORY # EMPLOYED AFTER COMPLETION PURCHASE EXISTING EXPANSION REFINANCE OF PROJECT *If purchasing equipment, attach list of equipment to be purchased. CURRENT DEBT FINANCING REQUESTED TERM (MONTHS) RATE (%) INTERIM LENDER CONTACT ACCOUNTANT PHONE PERMANENT LENDER CONTACT LEGAL COUNSEL PHONE BANK OF BUSINESS ACCOUNT CONTACT DISTRIBUTION OF LOAN PROCEEDS SOURCES (LENDER USE ONLY) BANK USE OF FUNDS BANK OWNER CITY/LDC LDC BLDG. ACQ. CITY LAND ACQ. EQUITY NEW CONSTR. JDA RENOV./EXP. SBA WORKING CAP. OTHER MACH. & EQUIP. CURRENT DEBT OTHER S
2 COLLATERAL ESTIMATED SOURCE OF EXISTING LIEN ASSET YES/NO VALUE VALUE IN DOLLARS LIEN HOLDER ACCOUNTS RECEIVABLE INVENTORY REAL ESTATE OTHER: BUSINESS FINANCIAL INFORMATION EXISTING DEBTS AMOUNT OF DEBTOR NAME AND ACCOUNT MONTHLY INTEREST MATURITY DEBT ACOUNT NUMBER NUMBER PAYMENT RATE DATE COLLATERAL REFERENCES VENDOR NAME CONTACT NAME TELEPHONE NUMBER NATURE OF BUSINESS LENDER NAME TYPE OF ACCOUNT ACCOUNT # ACCOUNT BALANCE NAME OF COMPETITOR LOCATION OF COMPETITOR HOW DOES YOUR COMPANY COMPETE?
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4 COMMUNITY CAPITAL FUND PERSONAL FINANCIAL STATEMENT Please complete all information, sign, and date form PERSONAL INFORMATION NAME (PRINT): LAST, FIRST & MIDDLE BIRTH DATE SOCIAL SECURITY NO. U.S. CITIZEN HOME PHONE Yes No STREET ADDRESS CITY STATE ZIP Own YEARS RENT/MTG AVG MTLY Rent PAYMENT UTILITIES Other PREVIOUS ADDRESS CITY STATE ZIP Own YEARS # OF DEPENDENTS Rent (count yourself as one) Other EMPLOYER ADDRESS CITY STATE ZIP WORK PHONE POSTION DEPARTMENT/UNIT LENGTH OF EMPLOYEMNT TYPE OF BUSINESS yrs. mos. FORMER EMPLOYER, ADDRESS AND YOUR POSITION ANNUAL SALARY THERE LENGTH OF EMPLOYMENT HAVE YOU FILED BANKRUPTCY OR HAD ANY ARE YOU OBLIGATED TO PAY ALIMONY, CHILD SUPORT DO YOU HAVE A WILL? JUDGMENTS AGAINST YOU? OR MAINTENANCE PAYMENTS? no yes no yes no yes NAME OF EXECUTOR EXPLAIN ON ATTACHMENT EXPLAIN ON ATTACHMENT ASSETS LIABILITIES AND NET WORTH CASH ON HAND AND IN BANKS (A) NOTES DUE BANK (H) MARKETABLE SECURITIES (B) NOTES DUE OTHERS NON-MARKETABLE SECURITIES BROKER MARGIN ACCOUNTS ACCTS & NOTES RECEIVABLE (D) ACCOUNTS & BILLS DUE REAL ESTATE WHOLLY OWNED (E) INCOME TAX DUE PARTIAL INTEREST/REAL ESTATE (F) OTHER UNPAID TAXES & INTEREST AUTOMOBILES REAL ESTATE MORGAGES (E) CASH VALUE-LIFE INSURANCE (G) OTHER DEBT (ITEMIZE) OTHER ASSETS (ITEMIZE) LIABILITIES NET WORTH ASSETS LIABILITIES & NET WORTH ANNUAL INCOME CONTINGENT LIABILITIES SALARY JUDGMENTS COMMISSIONS & BONUSES DAMAGE CLAIMS DIVIDENDS/INTEREST GUARANTIES ACCTS & NOTES RECEIVABLE ENDORSEMENTS AND RENTAL INCOME ANY OTHER OBLIGATIONS OTHER INCOME OTHER UNPAID TAXES & INTEREST
5 Personal Income and Expenses (for year ending ) Annual Income Annual Expenses Annual salary, bonuses Mortgage/Rental Pmts and commissions Federal, State and Dividends and interest local taxes Rental Income Real estate taxes Other Income (explain) Insurance premiums Other loans, credit cards Alimony, child support Other expenses (tuition, miscellaneous) Total Annual Income Total Annual Expenses Notes:
6 (A) BANKING INFORMATION TYPE OF ACCOUNT BANK/S&L/CRDT UNION ADDRESS CITY/STATE ACCOUNT NUMBER BALANCE (B) MARKETABLE SECURITIES/MONEY MARKET FUNDS DESCRIPTION REGISTERED OWNER NUMBER OF SHARES COST SOURCE OF VALUATION MARKET VALUE OR FACE VALUE (C) NON-MARKETABLE SECURITIES DESCRIPTION REGISTERED OWNER NUMBER OF SHARES COST SOURCE OF VALUATION MARKET VALUE OR FACE VALUE (D) ACCOUNTS AND NOTES RECEIVABLE BORROWER & ADDRESS WHEN DUE ORIGINAL DATE ORIGINAL AMOUNT COLLATERAL BALANCE DUE (E) REAL ESTATE - WHOLLY OWNED DESCRIPTION & DATE TITLE IN PURCHASE MORTGAGE MARKET MONTHLY MORTGAGE LOCATION ACQUIRED NAME OF PRICE HOLDER VALUE PAYMENT BALANCE
7 (F) REAL ESTATE - PARTIALLY OWNED DESCRIPTION & LOCATION % OF YEAR OF MARKET YOUR VALUE OF EQUITY OWNERSHIP COST PURCHASE VALUE MORTGAGE (G) LIFE INSURANCE NAME OF COMPANY FACE AMOUNT BENEFICIARY LOANS CASH SURRENDER VALUE BALANCE DUE (H) NOTES & ACCOUNTS DUE BANKS AND OTHERS-INCLUDE ALL REVOLVING CREDIT AVAILABLE BANKS/STORE/COMPANY ACCOUNT HIGH SECURED BY TERMS MONTHLY CURRENT NUMBER CREDIT PAYMENTS BALANCE THE UNDERSIGNED CERTIFIES THAT THE INFORMATION PROVIDED HAS BEEN CAREFULLY READ AND IS TRUE, CORRECT AND COMPLETE. THE UNDERSIGNED FURTHER REPRESENTS THAT THERE ARE NO ENCUMBRANCES AGAINST ANY OF THE FOREGOING PROPERTY EXCEPT THOSE SPECIFICALLY DISCLOSED ABOVE. GBF IS AUTHORIZED TO VERIFY THE INFORMATION DISCLOSED AND TO PERFORM A CREDIT INVESTIGATION. THE UNDERSIGNED AUTHORIZES GBF, IF CREDIT IS GRANTED, TO GIVE CREDIT INFORMATION TO ANY CREDIT RE- PORTING SERVICE AND TO ADVISE OTHERS ABOUT ITS CREDIT EXPERIENCE WITH YOU. IT IS ALSO AGREED THAT THE FINANCIAL STATEMENT SHALL REMAIN THE PROPERTY OF GBF WHETHER OR NOT CREDIT IS GRANTED.
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