Loan Form

Bank Loan Application Form and Checklist

Primary Officer:    Prepared By:

Date Prepared:

Loan Request

Borrower:

Business Information: Form:

Date of Organization:

Type:

Management:

Ownership:

Guarantors (Typically the owner of the business):

Request:

Purpose:

Terms:

Source of Repayment: Primary:

Secondary:

Collateral Description:

Collateral Valuation:

Flood Hazard:

Environmental Concerns:

Borrower's Debt:

Borrower's Payment History:

Line of Credit Usage:

Low Balance:    # of Days at Zero:

Other Debts:

Depository Relationship:

Average Cost of Funds:

Trust Relationship:

Background Information:

Financial Statement:

Last 3 years of business financial statements and/or tax returns

Last 3 years of owner's personal tax return

Current personal financial statement

BUSINESS LOAN APPLICATION

Date:

New Relationship    Branch:

Existing Relationship    Officer:

BUSINESS INFORMATION

Business Name:

Address:

Telephone ( )    Tax I.D.

Individual Name(s):

Address:

Telephone ( )    Social Security #    Date of Birth:

Proprietorship    Partnership    Sub-Chapter S    Corporation    Non-Profit    Individual    LLC

Ownership Distribution (List stockholders, partners, owner names):

Name Title # of Years % SS#

Name Title # of Years % SS#

Name Title # of Years % SS#

Nature of Business    Year Established    Number of Employees

Years at Present Location    Own    Lease

Accountant Telephone ( )

Insurance Agent Telephone ( )

Attorney Telephone ( )

FINANCIAL INFORMATION

Bank of Account    Account Number

Credit Relationships: Please provide details of your business credit relationships below:

LOAN REQUEST

Amount of Loan Requested:    Type of loan:

Line of Credit

Term Loan

Requested Term of Loan

Business Home Equity

Commercial Real Estate

Specific Loan Purpose (Check all that apply)

Working Capital

Other type of loan required and purpose

Finance Purchase of Inventory

Finance Purchase of Equipment

Finance Purchase of Real Estate

Finance Purchase of Business

Refinance Existing Loan or Debts

Collateral Available* (Check all that apply)

All Assets (accounts receivable, inventory, machinery and equipment)

Specific Equipment (Please attach equipment list, including serial numbers or description of equipment, and invoices for new equipment.)

Real Estate (Please attach property address, legal description and a copy of most recent tax bill).

Square Feet    Acres

Cash on Deposit at (name of bank) Branch Account #

Personal Assets (As described in Personal Financial Statement.)

* Collateral: Loans are secured by collateral, which is property in which a security interest is granted to secure repayment of the loan. The loan collateral may include business assets, stocks, bonds, certificates of deposits, or personal assets. Consider (1) the value of the loan collateral must be equal to or greater than the amount of the loan, (2) expected economic life of collateral will be considered by the Bank in evaluating the collateral offered for the loan, (3) formal collateral appraisals may be required, and (4) a pledge of personal assets may be required as additional collateral for the business loan requested.

Guarantors** (Please list)

Name    Social Security #

Address

Name    Social Security #

Address

Name    Social Security #

Address

BUSINESS BACKGROUND INFORMATION

PERSONAL BUSINESS EXPERIENCE

MISCELLANEOUS INFORMATION

Are tax liabilities current? Yes No Settled through

Is the business an endorser, guarantor, or co-maker for any obligation not listed in the financial statements? Yes No

If yes, what is the contingent liability?

Has the business or principal owner ever declared bankruptcy? Yes No

If yes, provide details on a separate sheet.

Is the business a defendant in any lawsuit? Yes No

If yes, provide details on a separate sheet.

Are any of the business assets encumbered by liens or attachments of any type? Yes No

What By whom Amount $

What By whom Amount $

What By whom Amount $

Does the business have a pension fund? Yes No    profit-sharing plan? Yes No

If so, does the plan have any unfunded pension liabilities? Yes No Amount $

CERTIFICATION

The undersigned certifies that, to the best of his or her knowledge and belief, all information contained in this loan application and in the accompanying statements and documents is true, complete, and correct. The undersigned agrees to notify the Bank immediately of any material changes in this information. It is further agreed that, whether or not the loan herein applied for is approved, the undersigned will pay or reimburse the bank for the costs, if any, of surveys, title or mortgage examinations, appraisals, etc., performed by non-Bank personnel with the consent of the applicant. The undersigned authorizes the Bank to contact any bank and trade creditors it deems necessary without further notice, including, but not limited to, Dunn & Bradstreet reports or information from TRW Credit Data.

Business Name (print):

Applicant Title:

BUSINESS LOAN APPLICATION CHECKLIST

Please be sure all of the following documentation has been included in order for your business loan application to be processed.

Business Loan Application

Accountant-Prepared Business Financial Statements (Profit and Loss, Balance Sheet) for the past three fiscal years

Business Federal Tax Returns for past three fiscal years

Interim Financial Statements (if available)

Most Recent Federal Tax Returns for each principal owner listed in the first section of the Business Loan Application

Personal Financial Statement

Organizational Papers (Articles, d/b/a papers, etc.)

OTHER: