Decorah Small Business Revolving Loan Fund Application Name of Applicant: Street Address: State: Legal Entity Zip: Email: Sole Proprietorship Partnership Corporation Federal Employer ID#: Date Business Established: Contact Person: Limited Liability Corporation Ownership of Business Entity Is the applicant a United States Citizen or Entity? Has the applicant ever been in receivership or bankruptcy? Is there any legal action pending against the applicant? Has the applicant ever co-signed someone else s liabilities? 1
Does the applicant have any taxes in delinquent status or dispute? Are all state and federal income taxes filed? Other business names used by the applicant? If yes, please list. Use and Sources of Funds Uses of Funds (Enter Gross Dollar Amounts Rounded to the Nearest Hundreds.) Real Estate Acquisition Describe: New Construction and Facility Improvements Describe: Purchase or Repair of Machinery/Equipment Describe: Inventory Purchase Describe: Working Capital Describe: Acquisition of Existing Business Describe: Refinance Debt Describe: Other Describe: Total Funds Required Sources of Funds Personal Investment Describe where funds will come from: Financial Institution Payment Amount: Other Source: Payment Amount: Other Source: Payment Amount: Decorah Small Business Revolving Loan Fund Terms Requested: Payment Amount: Total Sources of Funds 2
Job Creation Please complete the following tables concerning jobs created or brought into the Decorah Area within the first two years of operation. Full-Time Hourly Employees Average Regular Number of jobs created or brought into the Decorah area. Part-Time Hourly Employees Average Regular Number of jobs created or brought into the Decorah area. Full-Time Salaried Employees Average Regular Number of jobs created or brought into the Decorah area. 3
Existing Employees Average Regular Hourly Rate Check benefits provided Health Insurance Portion of premium paid by employee: Is family coverage available? Y / N Dental Insurance Portion of premium paid by employee: Is family coverage available? Y / N Retirement Plan Describe: In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, nation origin, sex, religion, age, disability, or marital or family status. (t all prohibited bases apply to all programs.) If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at htttp://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866)632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202)690-7442 or email at program.intake@usda.gov. USDA is an Equal Opportunity provider and employer. 4
Required Attachments 1. To apply, applicants will need to submit a 25.00 non-refundable application fee. 2. Personal resume(s) of company management and brief history of the company. 3. Business plan. 4. Current personal financial statement. 5. Current credit report. 6. Current balance sheet and YTD profit and loss statements for each of the past 3 years. (if available) 7. Business balance sheets an profit and loss statements for each of the past 3 years. (if available) 8. Three years income and expense projections. 9. Federal Tax returns filed by the business for the previous three years, if the applicant is a sole proprietorship, partnership or corporation that does not have audited financial statements. 10. Executed Form AD-1048; Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion. 11. Executed Form RD 400-4 Assurance Agreement 12. Data Collection Information I certify that everything I have stated in this application and on any attachments is correct. The Decorah Area Chamber of Commerce is authorized to make all inquiries it deems necessary to verify the accuracy of the information contained herein and to determine the creditworthiness of the undersigned. Applicant(s) will promptly notify Decorah Small Business Revolving Loan Fund of any subsequent changes that would affect the accuracy of this Statement. Decorah Small Business Revolving Loan is further authorized to answer any questions about Decorah Small Business Revolving Loan Fund s credit experience with Applicant(s). By signing below, each representative of the Applicant declares that he/she has read and understands the statement above. Signature Date: Signature Date: 5
DATA COLLECTION INFORMATION REQUIRED PER ASSURANCE AGREEMENT ***IMPORTANT NOTICE*** In order to meet the requirements of the Federal Register Vol 62. 210, Revision to the Standards for the Classification of Federal Data on Race and Ethnicity, all application forms for Rural Development financed programs must include below the signature and date block the following disclosure statement: The following information is requested by the Federal Government for certain types of loans, in order to monitor the lender s compliance with equal credit opportunity. You are not required to furnish this information, but are encouraged to do so. The law requires that a lender may neither discriminate on the basis of this information nor on whether you choose to furnish it. However, if you choose not to furnish it, under Federal regulations, this lender is required to note race/ethnicity on the basis of visual observation or surname. If you do not wish to furnish the above information, please check the box below. I do not wish to furnish this information. Date: Ethnicity: Hispanic or Latino t Hispanic or Latino Race: (Mark one or more) White: Black or African American American Indian/Alaska Native Native Hawaiian or Other Pacific Islander Asian Gender: Male Female Date: 6
Summary Of Project Costs And Proposed Financing Sources Use of Funds Cost Source A Source B Source C Source D Source E Land Acquisition Site Preparation Building Acquisition Building Remodeling Machinery & Equipment Furniture & Fixtures Working Capital Other: Source Identifications/Terms Source Amount Type Rate Terms Source A: [Name] Revolving Loan Fund Source B: Source C: Source D: Source E: Amount requested from Decorah Small Business Revolving Loan Fund: Term Requested: 7