Business Finance Questionnaire

Business Finance Questionnaire and Agreement

Applicant (Business) Name:     Finance Provider Name:

Recitals

WHEREAS, Applicant seeks financing, credit accommodations, or advisory services and has provided the factual and financial information requested in this Business Finance Questionnaire to enable evaluation of Applicant's eligibility; and

WHEREAS, Finance Provider requires accurate, complete, and current financial, organizational, and legal information concerning Applicant to evaluate, structure, and document any financing or advisory relationship; and

WHEREAS, the parties intend that completion of this Questionnaire and execution of the accompanying Agreement will govern the exchange of information and certain commercial terms described below.

Business Identification

Corporation    LLC    Partnership    Sole Proprietorship    Other:

Primary Contacts

Financial Summary (Most Recent Fiscal Year)

Annual Revenue: $     Net Income (Loss): $

Total Assets: $     Total Liabilities: $

Banking and Credit

Outstanding Litigation or Claims: None reported     If yes, provide details:

Tax and Compliance

Is the Applicant in good standing for federal and state tax obligations?    Yes    No

Financing Request and Use of Funds

Requested Amount: $     Desired Term (months):

Scope of Work

Describe the services, deliverables, and responsibilities to be provided by Finance Provider and Applicant as part of the contemplated financing or advisory engagement.

Payment Terms

Advisory / Origination Fee: $     Payment Schedule: One-time Monthly Other:

Late Payment Fee (percent per month):

Term and Termination

Agreement Start Date:     Agreement End Date:

Termination for Convenience: Either party may terminate this engagement upon written notice to the other party delivered not less than days prior to termination. Termination shall not relieve either party of obligations accrued prior to termination.

Confidentiality

Each party acknowledges that information disclosed in connection with this Questionnaire and any resulting engagement may be Confidential Information. Confidential Information shall mean non-public business, financial, and technical information disclosed by either party. The receiving party shall not use or disclose Confidential Information other than as necessary to evaluate or perform the financing or advisory services, except as required by law. Reasonable steps shall be taken to protect Confidential Information from unauthorized disclosure.

Representations and Warranties

Applicant represents and warrants that the information provided in this Questionnaire is true, complete and correct as of the date provided, and that no material information has been omitted. Applicant agrees to promptly notify Finance Provider of any material changes to the information supplied.

Governing Law; Entire Agreement

Governing Law: The parties agree that this Questionnaire and any resulting agreement shall be governed by and construed in accordance with the laws of the state of , without regard to conflicts of law principles.

Entire Agreement: This Questionnaire, together with any executed engagement letter or financing documents, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior understandings and agreements, whether written or oral.

Certification and Authorization

By signing below, Applicant certifies that the information provided in this Questionnaire is accurate and authorizes Finance Provider and its agents to verify any information provided and to obtain credit and background reports as necessary to evaluate the financing request. Applicant further agrees to provide supporting documentation upon request, including but not limited to financial statements, tax returns, bank statements, and corporate records.

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