PROJECT INTAKE FORM

PROJECT / CONTACT INFORMATION

Project Name: Contact Person: Street Address City, State, ZIP Phone Cell Fax Email Address

BORROWERS LOAN REQUEST

Purpose of oan: oan !erm "Desired#: Interest $ate "Desired#: Interest $eser%es: !otal Project Cost: Principal Cash Contri&utions: Principal ' (ther Collateral: !otal Soft Costs Expended to )ate: oan Amount $e*uested: Completed +alue: oan to +alue $atio: ender (ri,ination: $eferrin, -ro.er Fees:

USE OF FUNDS
TOTAL COST and Ac*uisition: and )e%elopment: Ne/ -uildin, Construction: Construction Contin,ency "012# Architecture3En,ineerin,: Sur%ey 3 Appraisal 3 Feasi&ility: machines Site )e%elopment 3 Construction: oan Consultin, Fees: and and (peratin, e*uipment 3 start up costs: )e&t $efinance: Professional 3 e,al Fees: Franchise Fees: Insurance 4 !axes: 5isc6 Expenses: (ther "Specify#:in,redients (ther "Specify#:stoc. pac.a,e $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ AMOUNT BORROWER PAID TO DATE

ESS: ESS: ESS: ESS:

TOTAL PROJECT COST -orro/er7s Cash Injection Seller Financin, (ther "Specify#: (ther "Specify#: TOTAL LOAN AMOUNT REQUESTED

$ $ $ $ $ $

PROPERTY DESCRIPTION
!ype of $eal Estate ocation of $eal Estate Address City 3 State 3 Zip Code S*uare Foota,e3Acres of Property 5onthly 5ort,a,e "or ease# Payment ist of )e&t or -ac. !axes A,ainst Property Percenta,e of Property (ccupied

LOANS INVOLVING REAL ESTATE

Are you purchasin, real estate usin, the su&ject loan8 Are you under contract to purchase8 Amount of Earnest 5oney3)eposit: 9as an Appraisal &een done8 Appraised +alue: )ate of Appraisal: 5AI Appraisal8 9o/ is the property currently :oned8 Is the property fully entitled8 ;hat permits and appro%als ha%e &een ,ranted8 ;hat additional permits and appro%als are re*uired8 9o/ many months /ill it ta.e to complete the project8

ADDITIONAL COLLATERAL
Property !ype Address City 3 State 3 Zip Code +alue of Property 0st ien -alance <nd ien -alance

PRINCIPAL OWNERS (must a !u"t #!$ %&&' !# t() !*")$s(+, !# t() -us+")ss.
ist &elo/ all officers, directors, partners, o/ners, co'o/ners, and stoc.holders6 Page 2 of 6

FULL LEGAL NAME

TITLE

% OWNED

ACTIVE

IN

COMPANY?

AFFILIATES
ist &elo/ all &usiness concerns in /hich the applicant Company or any of the indi%iduals listed in the o/nership section ha%e any o/nership6 =se additional sheets if necessary6

COMPANY NAME

OWNER (applicant, company or indi%iduals

OF

OWNERS!IP

PROPOSED BORROWER INFORMATION

Company Name !ype of Entity !ax I) Num&er Prior Project Experience Street Address City 3 State 3 Zip Code County ;e& Site State of Incorporation )ate of Incorporation Country Num&er of Employees:

BORROWER PRINCIPAL(S. INFORMATION

P"#n$#%al (& Name Company Name Page 3 of 6

(ccupation Adjusted >ross Income Adjusted >ross Income Adjusted >ross Income !otal Assets i*uidity $eal Estate 9oldin,s Net ;orth SS Num&er ) Num&er 4 State Credit Score Street Address City 3 State 3 Zip Code Phone Email P"#n$#%al (' Name Company Name (ccupation Adjusted >ross Income Adjusted >ross Income Adjusted >ross Income !otal Assets i*uidity $eal Estate 9oldin,s Net ;orth SS Num&er ) Num&er 4 State Credit Score Street Address City 3 State 3 Zip Code Phone Email P"#n$#%al (( Name Company Name (ccupation Adjusted >ross Income Adjusted >ross Income Adjusted >ross Income !otal Assets i*uidity $eal Estate 9oldin,s Net ;orth SS Num&er ) Num&er 4 State Credit Score Street Address City 3 State 3 Zip Code Phone Email P"#n$#%al () Name

<101 <100 <10<

<101 <100 <10<

<101 <100 <10<

Page 4 of 6

Company Name (ccupation Adjusted >ross Income <101 Adjusted >ross Income <100 Adjusted >ross Income <10< !otal Assets i*uidity $eal Estate 9oldin,s Net ;orth SS Num&er ) Num&er 4 State Credit Score Street Address City 3 State 3 Zip Code Phone Email

ATTORNEY INFORMATION
Name Firm Name Firm Address City, State, ZIP -usiness !elephone Num&er -usiness Fax Num&er Cell Phone ?ears Experience in Profession E'mail Address

CPA INFORMATION
Name Firm Name Firm Address City, State, ZIP -usiness !elephone Num&er -usiness Fax Num&er Cell Phone ?ears Experience in Profession E'mail Address

BAN/ INFORMATION
Name Page 5 of 6

-an. Name -an. Address City, State, ZIP -usiness !elephone Num&er -usiness Fax Num&er Cell Phone ?ears Experience in Profession E'mail Address

E0ECUTIVE SUMMARY

E0IT STRATEGY

REFERRING AGENT INFORMATION

Company Name: Contact Name: Email Address: (ffice: Cell: Address:

Page 6 of 6