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AUGUSTA-RICHMOND COUNTY ECONOMIC DEVELOPMENT LOAN FUND APPLICATION REQUEST Amount of Loan Request Term of Interest GENERAL INFORMATION Name of Operating Address of Zip Phone BUSINESS INFORMATION R Corporation (Attach Articles of Incorporation) Federal Tax ID R Partnership (Attach Partnership Agreement) R Proprietorship R Franchise (Attach Franchise Agreement) R Manufacturing Type of (Example: grocery, retail, manufacturing, etc). Date Years in Business R New R Existing Location R Own R Lease per month) PROJECT SUMMARY Give brief narrative/description of the project below: ---PAGE BREAK--- ECONOMIC IMPACT A. # Low/Moderate Income Jobs To Be Created # Full Time Jobs # Part Time Jobs Title of Position(s) Rate of Pay $ B. # Low/Moderate Income Jobs To Be Retained # Full Time Jobs # Part Time Jobs Title of Position(s) Rate of Pay $ USE OF PROCEEDS Land Acquisition Land Improvements Construction/Renovations Cost(s) Purchase Machinery and Equipment Purchase Existing Land & Building Working Capital (Breakdown if over $5,000) Inventory Professional Fees Other TOTAL USES OF PROCEEDS SOURCES OF FUNDS TOTAL SOURCES OF FUNDS 100% (EX: Owner Equity, ARCEDLF, Bank, and other Lenders) (20% Cash injection required for start-up business) COLLATERAL The collateral offered to secure this loan is as follows: (EX: Automobile, land, property, life insurance policy (Cash Surrender Value), etc.)) Automobile Model Model Property Value: Tax Assessor’s Value Appraisal Value (Attach Copy of Deed, Appraisal, Tax Assessor’s Card) Other Value Value Value TOTAL COLLATERAL OFFERED ---PAGE BREAK--- GUARANTEES/LIFE INSURANCE/OTHER Personal and Business guarantees required. GROSS RECEIPTS Year-to-date Last year 19___ 2-years ago 3-years ago INDEBTEDNESS Furnish the following information on all installment debt owed by the business or in relation to the business: To Whom Amount Date Balance Amount Matures Security TELL US ABOUT YOURSELF YOUR SPOUSE Social Security # Social Security Age Date of Age Date of EMPLOYMENT YOURSELF YOUR SPOUSE Current Current State___ State_____ Telephone # ( How Long How Long Income Income Do You Own Your Home? R Yes R No Mortgage Payment per month Do You Rent? R Yes R No Rent Payment per month Name & Address of Mortgage/Leasing Company: ---PAGE BREAK--- PERSONAL DEBT Furnish the following information on all debt: To Whom Amount Date Balance Amount Matures Security BANKING RELATIONSHIP Name of State______ Type of Name of Name of State______ Type of Name of CLIENT DATA Minority Group (Check One) Marital Status (Check One) R American Indian R Single R Asian American R Married R Black/African American R Divorced R Cuban American R Separated R Eskimo & Aleut R Widowed R Mexican R Puerto Rican R Non-Minority R Other Gender: R Male R Female # of Dependents EDUCATION Name Address Graduate – Y/N Diploma – Y/N High Technical Graduate ---PAGE BREAK--- MANAGEMENT/OWNERSHIP List all proprietors, partners, officers, directors, and holders of stock. 100% ownership must be shown.* Name Social Security # Complete Address Ownership % NOTE: Percentage of ownership must total 100%. Have any of the persons listed above ever been charged with or convicted of any criminal offenses, other than a minor traffic violation?R Yes R No If yes, please explain below: Has the applicant or any person listed above been connected with, been in receivership, or adjudicated as bankrupt? R Yes R No If yes, please explain below: Has bankruptcy been discharged? R Yes R No Date ---PAGE BREAK--- AGREEMENTS The applicant agrees, to the maximum extent possible, to use labor of low-income persons. The applicant certifies that neither they nor members of their families hold any legal or financial interest in the Augusta-Richmond County Commission, nor does any Commission member own any legal or financial interest or influence with the applicant. The undersigned assures that it does and/or will at all times comply with Title VI of the Civil Rights Act of 1964. “Nondiscrimination in Federally Assisted Programs,” (42 U.S.C. 2000d-2000d-4) and that it will not discriminate on the basis of race, color, religion, national origin, age, physical or mental handicap, sex, or marital status with respect to its day to day operations. The applicant certifies that the financing they are requesting is not available from other federal, state, or private sector programs. The applicant certifies that those facilities under its ownership, lease or supervision which will be utilized in the accomplishment of the project noted above, are not listed on the Environmental Protection Agency's (EPA) List of Violating Facilities. The undersigned will notify Augusta-Richmond County of the receipt of any communication from EPA of activity that the facility is under consideration for listing on the Violating Facilities list. CERTIFICATION The undersigned hereby certifies that all information contained above and in exhibits attached hereto is true and complete to the best knowledge and belief of the applicant(s) and is submitted for the purpose on inducing Augusta-Richmond County to consider his/her financial request. This applicant(s) also certifies that by providing false information may disqualify him/her/them from participation in this program. This also certifies that Augusta-Richmond County, Housing and Neighborhood Development Department staff is authorized to check the applicant’s credit and employment history and to ask questions about their experiences with the applicant for the purposes of considering the financial assistance requested in this application. Whether or not the financial assistance herein applied for is approved, applicant agrees to pay for the closing cost of any survey, title or mortgage examinations, appraisals, etc., performed by non-Augusta-Richmond County personnel with consent of the applicant. APPLICANT SHALL IMMEDIATELY NOTIFY THE AUGUSTA-RICHMOND COUNTY HOUSING AND NEIGHBORHOOD DEVELOPMENT DEPARTMENT OF ANY CHANGE(S) IN OR ADDITION TO THE INFORMATION ABOVE. BY: Applicant Signature Signature TITLE: SEAL TITLE: ---PAGE BREAK--- CHECKLIST FOR BUSINESS PLAN/LOAN PACKAGING I. BUSINESS BACKGROUND Narrative on Business (Company Profile) Resumes on owners/managers II. THE MARKET Target Market Existing or Potential Customers (if applicable) Competition III. ADVERTISING AND PROMOTION Media to be used (radio, television, newspapers, flyers, etc.) Promotional Strategies (discounts, coupons, sales, etc.) IV. FINANCIAL DATA Current Personal Financial Statement (All principals) Current Business Financial Statement (Previous 2 years if existing business) 12-month Profit and Loss (Income) Statement 12-month Cash Flow Statement Balance Sheet (as of date of loan) Explanation of Sales Projections Personal and Business Income Tax Returns (past 2 years for all principals) Credit Report (All principals) Amortization Schedule V. OTHER SUPPORTING DATA Business License Partnership Agreement, if applicable Articles of Incorporation, if applicable Vendor Quotes on Machinery & Equipment, Furniture & Fixtures, Renovations Lease Agreement, if applicable Sales Contract, (if real estate or business being purchased, if applicable) Franchise Agreement, if applicable Property Deed Appraisal, Tax Assessor’s Record Card Commitment letter(s) from other lender(s), if applicable Statement by applicant describing business ability and why applicant thinks business will succeed