Loan Application - The Panhandle Area Development District (PADD)

Request for Financial Assistance

Panhandle Area Development District

Date(Required)

Fund Requested(Required)

IRP

EDLF

Business Information

Business Name(Required)

Business Address(Required)

Business Phone(Required)

Country Phone Number

Business Website

Business Email(Required)

DBA (if used)

Business Description

In Business Since(Required)

Year or date business was established

Type of Business(Required)

e.g. Retail, Manufacturing, Service

Number of Full-Time Employees(Required)

Number of Part-Time Employees

Federal Tax ID #(Required)

Loan Information

Amount Requested ($)(Required)

Term Requested(Required)

e.g. 5 years

Security Offered(Required)

Do you agree to implement your project within the guidelines of federal regulations?(Required)

Yes

Current Bank(Required)

Current Bank Address

Current Bank Phone

Country Phone Number

Bank Officer

Status of Bank Loan(s)

County of Business Location(Required)

City/Village of Business Location(Required)

Business Owner #1

Legal Name (Owner 1)(Required)

Personal Address (Owner 1)(Required)

Phone # (Owner 1)(Required)

Country Phone Number

Social Security # (Owner 1)(Required)

Stored securely.

Email Address (Owner 1)(Required)

Percent of Ownership (Owner 1)(Required)

Please enter a number from 0 to 100.

Are you a Minority? (Owner 1) — for statistical purposes only

Yes

Prefer not to say

Do you have a Disability? (Owner 1) — for statistical purposes only

Yes

Prefer not to say

Are you female? (Owner 1) — for statistical purposes only

Yes

Prefer not to say

Business Owner #2 (if applicable)

Leave blank if there is only one owner.

Legal Name (Owner 2)

Personal Address (Owner 2)

Phone # (Owner 2)

Country Phone Number

Social Security # (Owner 2)

Email Address (Owner 2)

Percent of Ownership (Owner 2)

Please enter a number from 0 to 100.

Are you a Minority? (Owner 2)

Yes

Prefer not to say

Do you have a Disability? (Owner 2)

Yes

Prefer not to say

Are you female? (Owner 2)

Yes

Prefer not to say

Project Narrative

Project Description(Required)

Describe the project this loan will fund.

Proposed Sources and Uses of All Project Funds(Required)

Indicate if funds have been committed and any associated terms.

Employment Information(Required)

Number, type, projected start dates, and wage levels of jobs to be created or retained because of the project.

Disclosure Questions

If the answer is Yes, please explain in the box that appears.

Does the business or its principals have patent protection, copyrights, or trademark protection on any portion of the products, services, or intellectual property associated with this project?(Required)

Yes

Please explain

Have you ever been turned down for a business loan?(Required)

Yes

Please explain

Have you ever declared bankruptcy?(Required)

Yes

Please explain

Are there any judgments or pending lawsuits against the business, or any of its principals?(Required)

Yes

Please explain

Are any current business loans delinquent?(Required)

Yes

Please explain

Are you or will you be doing any major business with any Panhandle Area Development District staff or board members?(Required)

Yes

Please explain

Authorization

I understand that completion and submission of this form is in no way a guarantee of funding. Everything that I have stated in this application is true, accurate and complete to the best of my knowledge. I understand that the Panhandle Area Development District will retain this application whether or not it is approved. The Panhandle Area Development District is authorized to verify any information provided in conjunction with this application, including credit and employment history, and to inquire with my bank or other banks the business has used.

Authorized Signature (Full Legal Name)(Required)

Title(Required)

Signature Date(Required)

Panhandle Area Development District Request for Financial Assistance

Request for Financial Assistance

Business Information

Business Description

Loan Information

Business Owner #1

Business Owner #2 (if applicable)

Project Narrative

Disclosure Questions

Authorization

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