CITY OF
LB 840 Loan Application
Please
Answer Every Question (If question does not apply mark NA)
A. Business Information:
Name
of Business to Receive Assistance: ________________________________________
Federal
ID#: _______________________________________________________________
Address:
__________________________________________________________________
__________________________________________________________________________
City State Zip
__________________________________________________________________________
Contact Person Telephone #
__________________________________________________________________________
Fax # E-Mail Address
Business Classification: (Mark One)
Manufacturing Warehousing & Distribution
Service
Research & Development
Administrative Mgmt HDQT Other
Business Organization: (Mark One)
Proprietorship Corporation – Status___________
Partnership(Type)___________ Other_______________________
Does
the Company have a Parent or Subsidiaries? Yes No
If
Yes, Identify Name: ________________________________________________________
Address:
__________________________________________________________________
__________________________________________________________________________
City
State Zip
Business
Type:
Start- Up (0-5
Years Old) Buy out Existing*
*If existing, Years in
Business___________________
Ownership Identification: List officers, directors, partners, owner,
co-owners and all stockholders with 20 percent or more of the stock. Enter
under Minority Code, a “1” if the person identified is a woman: a “2” if a
member of a minority group; and “3” if a disabled person.
Name Title Ownership Percent Minority
Code
________________________________________________________________________________
Personnel: (Full-Time-Equivalent,
FTE is based upon 2,080 hours per year)
Existing Number of Full-Time-Equivalent Positions: _______________________________________
Full-Time Equivalent Positions to be created with
18 month of Application Approval: _____________
Total number of seasonal and/or Full-Time
Equivalent Jobs Created: _________________________
(i.e. Jobs which will be available for at least 3
continuous months and recur annually)
B. Project
Information
Uses of Funds Total Project Cost LB840 Funds Requested
Land
Acquisition __________________ _____________________
Building
Acquisition/Renovation
__________________
_____________________
New
Facility Construction
__________________
_____________________
Acquisition of Machinery/Equipment
__________________
_____________________
Working
Capital (Includes Inventory)
___________________
_____________________
Other
(Specify)
__________________
_____________________
TOTAL: ___________________ _____________________
C. Sources of Funds
Note: Public sources of
financing require the participation of a bank and/or an injection of equity (non-debt) funds.
Participating
Lender Information:
Name
of Lending Institution: ____________________________________________________
Address:
____________________________________________________________________
___________________________________________________________________________
Contact Person
Telephone #
Type of Assistance applied
for: Amount:
Grant: _____________
Loan: _____________
Guarantee: ______________
D. Equity Information:
Amount available by business or owners
for investment: $____________________________
Project
Location (Choose one):
Within
the City Limits of:
___________________________________________________________________
Name of City
Population of City
Outside of City Limits, but within the Zoning
Jurisdiction of:
___________________________________________________________________
Name
of City
Population of City
Unincorporated
Area in:
___________________________________________________________________
Name of County
Signatures: I
certify that everything I have stated in this application and on any
attachments is correct. You may keep
this application whether or not it is approved.
By signing below, I authorize you check by credit and employment history
and to answer questions others may ask you about my credit record with
you. I understand that I must update
credit information at your request if my financial condition changes.
__________________________________ ______________________________
Applicant’s Signature Date Other
Signature Date
(if applicable)
Attach the Following:
1.
A brief description of the business and personal history and summary of
request.
2.
Two (2) year historical balance sheets and operating statements. Current
Statements less than (60) days old. Start up: provide projected year-end
statements for first two (2) years of operation.
3.
Personal Financial Statement for each person owning twenty (20) percent
or more of the business.
4.
List of Current Obligations for Existing Business.
5.
For new business and existing business expanding into a new product
line, please include a business plan.
6.
Last two (2) years of tax returns (Business and Personal).
7.
Other documentation may be requested.