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1 City of Kalispell Post Office Box 1997 - Kalispell, Montana 59903-1997 Telephone (406) 758-7000 Fax - (406) 758-7758 Brownfields Clean-Up Revolving Loan Fund Application Application fee of $200.00 payable to the City of Kalispell must be attached APPLICANT INFORMATION: Business Contact Contact Phone Federal Tax ID Year business was Business Mailing Business Phone Business Please list all managers, owners, and directors of the business, their time employed and their position: Name: Employed Since (year): Title: PROJECT: Project Requested Brownfields Clean-Up Funding Amount: $ Brief Description of Project Brief Description of ---PAGE BREAK--- 2 Proposed Project Are there any pending lawsuits regarding the project site? If yes, please Have you submitted a voluntary clean-up plan to the Montana Department of Environmental Quality? If yes, please attach a copy of the plan. If no, what is the estimated date that a clean-up plan will be submitted to FUNDING: Total cost of project Please enter the source and amount of ALL funding that may be used to complete the proposed activity. Funding Source : Funding Amount: Committed/Uncommitted: COLLATERAL: Collateral Value and description of Is there a current appraisal for the property: Yes:___ Is there a lienholder on the property: Yes:___ If yes, include the name of the financial institution and amount owed: EMPLOYMENT: Number of full time jobs created by project:________ Number of part time jobs created:________ Average wage per hour for full time Average wage per hour for part time jobs:_____ ---PAGE BREAK--- 3 ADDITIONAL REQUIREMENTS: Please include the following documents with your application: Information release form Confidentiality and non-disclosure agreement Site eligibility Form Environmental Phase I and Phase II Most recent appraisal on the property Clean-up cost budget and/or invoices Corporate documents and/or proof of nonprofit status Current personal financial statements for each party having over 20% ownership of the business. Personal tax returns for the last three years for each party having over 20% ownership of the business. Resume of each party having over 20% ownership of the business. Current year to date financial report for existing businesses. Financial reports for the last three years of operation for existing businesses. Tax returns for the last three years of operation for existing businesses. Completed business plan with forecast for the next three years. (Please ensure all forecast assumptions are adequately disclosed.) ---PAGE BREAK--- 4 I/we hereby authorize the City of Kalispell or any of its affiliates to make all inquiries it deems necessary to verify the accuracy of this information provided herein, and for any other purpose related to my loan/grant transaction with them. Further, I/we hereby certify that the enclosed application information, including any attachments/exhibits, is valid and correct to the best of my knowledge. I/we certify that employees and applicants for employment of our company are not discriminated against on the basis of race, color, national origin, religion, age, handicap or sex; and furthermore, I/we realize this document is just an application for a loan or grant. A loan or grant request shall not be considered approved until formal approval is made by the Economic Development Revolving Loan Fund Committee. I/we authorize the City of Kalispell to contact any banks listed on this application or identified in other sources about the project including financial statements and to pull and/or view my/our credit report. I/we certify and affirm by my/our signature that the information contained in and otherwise supplied as part of this application, is complete and current to the best of my/our knowledge. I/we further understand that intentional misrepresentation of facts may be basis for a denial of credit. Authorized Signature Date Authorized Signature Date This is an Equal Opportunity Program. Discrimination is prohibited by Federal Law. Complaints of discrimination may be filed with the USDA Director, Office of Civil Rights, Room 326-W, Whitten Bldg., 1400 Independence Ave., SW, Washington, DC 20250-9410 Return completed application and application fee to: City of Kalispell Economic Development Department 201 First Avenue East, Kalispell, MT 59901 [PHONE REDACTED] ---PAGE BREAK--- 5 INFORMATION RELEASE FORM I (We) hereby grant the City of Kalispell Revolving Loan Fund Program access to all necessary information concerning my (our) income, employment, bank relationships, payable and trade accounts, credit, business relationships and other sources of financial information. In addition I (we) give my (our) permission to obtain a copy of my (our) individual credit report(s). I (we) give my (our) permission for the above mentioned information to be presented to the loan review committee for review as a part of my (our) project. Company Name Signature and Title of Authorized Company Rep. Company Federal ID Number Address for the last 2 years Signature – Individually Social Security Number Date of Birth (Please print full name) Address for the last 2 years Signature – Individually Social Security Number Date of Birth (Please print full name) Address for last 2 years ---PAGE BREAK--- 6 CITY OF KALISPELL Revolving Loan Fund Loan Application Additional Information Form The following information is requested by the Federal Government in order to monitor compliance with Federal Laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the racial/national origin of the individual applicants on the basis of visual observation or surname. Ethnicity: Hispanic or Latino Not Hispanic or Latino Race (Mark one or more): White Black or African American American Indian/Alaska Native Asian Native Hawaiian or Other Pacific Islander Gender: Male Female This is an Equal Opportunity Program. Discrimination is prohibited by Federal Law. Complaints of discrimination may be filed with the USDA Director, Office of Civil Rights, Room 326-W, Whitten Bldg., 1400 Independence Ave., SW, Washington, DC 20250-9410 Company Name Name Date