Assets Liabilities

Quick Pre-Qualification Checklist
of Forms and Information

Additional Items Needed to Complete the Loan File

Assets Liabilities

Quick Pre-Qualification Checklist of Forms and Information

Additional Items Needed to Complete the Loan File

Assets Liabilities

Quick Pre-Qualification Checklist
of Forms and Information

Introduction:

Introduction:

STATEMENT OF PERSONAL HISTORY

STATEMENT OF PERSONAL HISTORY

STATEMENT OF PERSONAL HISTORY

Are you presently under indictment, on parole or on probation?

TOTAL LOAN REQUEST

INCOME

MONTHLY

Yearly

Are you presently under indictment, on parole or on probation?

TOTAL LOAN REQUEST

INCOME

MONTHLY

Yearly

Small Business Administration
Loan Application Form

Borrower Name:	Current Address:
Trade Name:
Type of Business:	Future Address:
Business Phone:
Fax Number:	Rent or Own:		Rent Own
		Contact Person:
		Contact Phone:

Are you presently under indictment, on parole or on probation?	Yes No
If yes, please explain:
Have you ever been charged with, arrested, and/or convicted of any criminal offense other than a minor motor vehicle violation?		Yes No
If yes, please explain in detail, sign and attach to the “Statement of Personal History” form in application!

Borrowing Entity: Corporation:	Partnership		Limited Partnership
Sole Proprietorship	LLC		Other
Number of existing employees		# of employees after this loan

Estimated Project Costs

Costs/Uses of Funds - Please outline the use of funds in the space below. Be as specific as possible.

	TOTAL COSTS	COMMENTS
Land and Building (total costs)	$
New construction	$
Leasehold improvements	$
Machinery & equipment	$
Debt repayment	$
Inventory	$
Working capital	$
Fees	$
Other	$
Total Project	$ 0
Seller Financing	$ 0
Cash Injection	$
TOTAL LOAN REQUEST	$ 0

Ownership of Applicant Company

(Show 100% of ownership including all proprietors, partners, officers, directors and any holders of outstanding stock)

Name/Title	% Owned	Compensation	Active?	Citizen?	Green Card?
	%
	%
	%
	%
	%

Sources of Applicants Capital Injection and/or Equity

When purchasing Real Estate, Equipment, or other assets; between 10% to 30% or more may be required as cash injection toward the purchase. Please list the location of the funds to be used as capital / cash injection.

Amount		Where Funds are held or Source of Equity Injection
$
$
$

Collateral For This Loan

Please list the collateral that will be offered for this loan.





Estimated Value of Collateral			Source of Valuation

Additional Information

Do any of the principals of the business have any ownership in other businesses? If yes, list all ownership under Affiliates section.		Yes No
Have any of the principals been arrested and/or convicted of a Felony or Misdemeanor, on parole or probation, or under Indictment? If yes, explain.		Yes No
Are any applicants a party to past or pending claims, lawsuit, judgement, or tax liens? If yes, attach full description.		Yes No
Have you ever applied or obtained an SBA Loan or assistance from SBA before? If yes, please state current status below.		Yes No
Status ( Loan Amount, Current Balance, Collateral):

Has any applicant filed Bankruptcy in past?	Yes No	If yes, attach full description.
Do applicants owe any past Taxes?	Yes No	If yes, attach full description.
Have you prepared a Business Plan?	Yes No	If yes, please attach
Have you completed cash flow projections?	Yes No	Please attach
List Important Trade References: 1		Phone
2		Phone

Bank Reference		Phone
Accountant Name		Phone
Attorney Name		Phone

Affiliates

List below all business concerns in which the Applicant Company or any of the individuals listed in the ownership section above have 20% or more ownership.

Company Name	Name, Type of Ownership	% of Ownership
		%
		%
		%
		%

Brief Description of the Primary Purpose for This Loan

Please provide a brief description of your Business and the primary need and use for SBA Loan Funds.

Attach Financial Information Here

Historic Business Financial Statements - This should include 3 years of: (Check All Attached)
	Business Income Statements (often called a Profit and Loss Statement)
	Business Balance Sheets (Assets and Liabilities on the Business)
	Business Tax Returns

Interim (Current) Business Financial Statement – Profit & Loss Statement and Balance Sheet

The most current Business Income Statement and Balance Sheet – dated 45 days or newer. Include with the Interim statement, an Accounts Receivable Aging and an Accounts Payable Aging dated the same as the Interim financial Statement.

3 Years Historic Personal Tax Returns
	Personal Tax Returns

Pro-Forma (Projected) Business Financial Statement and Assumptions to Projections
	Prepare a projection of your Income (Profit and Loss) Statement for 2 years into the future.
	Prepare Assumptions to Projections.

Current Accounts Receivable and Accounts Payable Aging
	Must balance to and be dated the same as the Interim Financial Statements noted above.

I/We hereby acknowledge that the information contained in the SBA Loan Application Package, including all attachments and exhibits are true and accurate as of the stated date(s). I/We further acknowledge that the loan approval will be in writing and subject to the terms and conditions set forth in a commitment letter signed by an officer of the institutional SBA lender we apply to.

Signature:

Date:

Signature:

Date:

Personal Financial Statement

U.S. Small Business Administration	As of (date)
Complete this form for : (1) each proprietor, or (2) each limited partner who owns 20% or more interest and each general partner, or (3) each stockholder owning 20% or more of voting stock and each corporate officer and director, or (4) any other person or entity providing a guaranty on the loan.

Name		Spouse’s Name:
Business Phone:		Residence Phone:
Residence Address:
Business Name of Applicant/Borrower

Cash in Banks

Accounts Payable

Describe in Section 2

Savings in Banks

Notes Payable

Describe in Section 2

IRA / Retirement

Installment Loans

Describe in Section 2

Cash Value Of Life Insurance Complete Section 8

Other Loans

Describe in Section 2

Stocks & Bonds

Describe in Section 3

Real Est. Loans

Describe in Section 4

Real Estate Owned

Describe in Section 4

Other Liabilities

Describe in Section 7

Automobile – Present Value

Unpaid Taxes

Describe in Section 6

Other Assets & Property

Describe in Section 5

Total Liabilities

$ 0

Net Worth

$ 0

Total Assets

$ 0

Equals

Total

$ 0

Section 1

Salary	$
Net Investment Income	$
Real Estate Income	$
Other Income	$	Describe other income:

Section 2 Notes Payable to Bank and Others (use attachment A if necessary)

Name and address of Note Holder	Original Balance	Current Balance	Payment Amount	Frequency (Monthly, etc.)	How Secured or Endorsed Type of Collateral
	$	$	$
	$	$	$
	$	$	$
	$	$	$
	$	$	$
	$	$	$
	$	$	$
	$	$	$

Personal Financial Statement Page 2.

Section 3 Stocks and Bonds (use attachments if necessary)

Number of Shares	Name of securities	Cost	Market Value Quotation/Exch.	Date of Quote	Total Value
		$	$		$ 0
		$	$		$ 0
		$	$		$ 0
		$	$		$ 0

Section 4 Real Estate Owned (List Each Parcel Separately. Use attachments if necessary.)

	Property A	Property B	Property C
Type of Property
Address of Property
Name and address of Title Holder
Date Purchased
Original Cost	$	$	$
Present Market Value	$	$	$
Name and Address of Mortgage Holder
Mortgage Account Number
Mortgage Balance	$	$	$
Monthly Payment	$	$	$
Status of Mortgage

Section 5 Other Personal Property and Other Assets (describe, if any is pledged as security, state name and address of lien holder amount of lien, terms of payment, and if delinquent, describe delinquency)

Personal Property (Estimated value of home furnishing, appliances, electronics, jewelry, etc.)

Section 6 Unpaid Taxes (describe in detail, as to type, to whom payable, when due, amount and to what property if any, a lien attaches)

Section 7 Other Liabilities (describe in detail)

Section 8 Life insurance Held (give face amount and cash surrender value of policies – name of insurance company and beneficiaries).

I authorize SBA/Lender to make inquiries as necessary to verify the accuracy of the statements made and to determine my credit worthiness. I certify the information contained in the Personal Financial Statement and the statements contained in the attachments are true and accurate as of the stated date(s). These statements are made for the purpose of either obtaining a loan or guaranteeing a loan. I understand FALSE statements may result in forfeiture of benefits and possible prosecution by the U.S. Attorney General (reference 18 U.S.C 1001).

Signature	Date	SSN:

Signature	Date	SSN:

Please note: The estimated average burden hours for this completion of the form is 1.5 hours per response. If you have any question or comments concerning this estimated or any other aspect of this information, please contact Chief Administrative Branch US small Business administration, Washington DC 20416 and clearance office, Paper Reduction Project (3245-0188), Office of Management and Budget. Washington, DC 20503

Personal Family Budget (Personal Financial Statement Attachment)

INCOME	MONTHLY	Yearly
Gross Salary or Draw (projected with new business)	$	$ 0
Spousal Salary (projected with new business)	$	$ 0
Gross Rental Income	$	$ 0
Interest / Dividend Income	$	$ 0
Other Income	$	$ 0
Total Income	$ 0	$ 0

EXPENSES

Residence Payment (Mortgage or Rent)	$	$ 0
Rental Property Mortgage	$	$ 0
Rental Expenses (impounds, cash expenses)	$	$ 0
Auto Loan Payments (List all debts on Financial Statement)	$	$ 0
Installment Payments (List all debts on Financial Statement)	$	$ 0
Credit Card Payments (List all debts on Financial Statement)	$	$ 0
Utilities & Phone	$	$ 0
Insurance Payments	$	$ 0
Food, Clothing	$	$ 0
Income Tax	$	$ 0
Property Tax	$	$ 0
Alimony	$	$ 0
Child Care/Support	$	$ 0
Other	$	$ 0
Miscellaneous (10% of Monthly Income)	$	$ 0
Total Expenses	$ 0	$ 0
Net Discretionary Income	$ 0	$ 0

I /we hereby certify that the above information is true and correct to the best of my/our knowledge and belief.

Signature

Date:

Signature

Date:

SOURCE OF CAPITAL INJECTION

SOURCE OF FUNDS			AMOUNT OF FUNDS


1. Cash on Hand			$ 0

2. Cash in Checking Account			$ 0
Name:
Bank:
Acct#:

3. Cash in Savings Account			$ 0
Name:
Bank:
Acct#:

4. Sale of Investments			$ 0
Details:

5. Finance obtained by additional mortgage on personal real estate			$ 0
Details:

6. Sale of Asset			$ 0
Details:

7. Business Assets (already obtained) being transferred to this business			$ 0
Details:

8. Loan from Family Member			$ 0
Details:

9. Loan from other source			$ 0
Details:

10. Gift			$ 0
Details:

11. Other:	Franchise Fees already paid		$0
Details:

	TOTAL CAPITAL INVESTMENT		$ 0
Other information about source of funds:



Signature		Title		Date:

Authorization to Release Information

The undersigned applicant hereby authorizes Diamond Financial Services, or any of its affiliates or lenders, to make all inquires it deems necessary to verify the accuracy of the information provided herein, and to determine my/our credit worthiness. The applicant hereby also certifies that all information in regards to credit worthiness is valid, accurate, and complete.

Additionally, the undersigned agree that Diamond Financial Services, any of its subsidiaries or lenders, at any time and in its sole discretion, may disclose the status of the purposed transaction and credit data and other information concerning or relating to the undersigned or the purposed transaction to the SBA, referral sources, franchisers, vendors, loan participants, and agents of both the undersigned and Diamond Financial Services.

Verifications will be processed and sent to Diamond Financial Services

Signature of Applicant	_____________________________________	Date	______________
Signature of Applicant	_____________________________________	Date	______________

Print Name	_____________________	Social Security #	______________________________	D.O.B._________
Print Name	_____________________	Social Security #	______________________________	D.O.B._________

Applicant Addresses

Current (at least 2 years)

_________________________________________________________________________

Previous (if above is less than 2 years)

_________________________________________________________________________

MANAGEMENT RESUME
(Additional forms available upon request)

Please fill in all spaces; use full first, middle and maiden names-no initials. If an item is not applicable, please indicate so. You may include additional relevant information on a separate sheet. Sign and date where indicated.

Name					SS#
First Middle Maiden Last

Date of Birth

Place of Birth

Residence Telephone

Business Telephone

Residence Address
	Street City State Zip

Previous Address
	Street City State Zip

Lived there from			To
	Month and Year			Month and Year

Spouse’s Name					SS#
First Middle Maiden Last

Are you employed by the U.S. Government?

Agency/Position

Are you a U.S. Citizen?

If no, give Alien Registration Number

Have you ever been charged with or convicted of any criminal offense other than a misdemeanor involving a motor vehicle violation? Yes No

If yes furnish details in a separate exhibit.

Are you current on all taxes?

Yes No

Do you have any liens/judgements ?

Yes No

EDUCATION

College or Technical Training Name & Location	Dates Attended From/To	Major	Degree or Certificate
	to
	to

MILITARY SERVICE BACKGROUND

Branch

From

Honorable Discharge

Rank at Discharge

Major assignment/accomplishment

WORK EXPERIENCE (List chronologically, beginning with present employment)

Company Name/Location
From	To	Title
Duties

Company Name/Location
From	To	Title
Duties

Company Name/Location
From	To	Title
Duties

I certify that the information contained in the Management Resume is true and correct as of the date below.

Signature:

Date

Return Executed Copies 1, 2, and 3 to SBA

OMB APPROVAL NO.3245-0178

Expiration Date:9/30/2006

United States of America

SMALL BUSINESS ADMINISTRATION

Please Read Carefully – Print or Type

Each member of the small business concern or the development company requesting assistance must submit this form in TRIPLICATE for filing with the SBA application. This form must be filled out and submitted by:

1. By the proprietor, if a sole proprietorship.

2. By each partner, if a partnership.

3. By each officer, director, and additionally by each holder of 20%

or more of the ownership stock, if a corporation, limited

liability company, or a development company.

Name and address of Applicant (Firm Name) ( Street, City, State, and Zip Code)

SBA District/Disaster Area office

Amount Applied for (when applicable)

File No. (If Known)

1. Personal Statement of: (State name in full, if no middle name, state (NMN) or if initial only, indicate initial.) List all former names used, and dates each name was used. Use a separate sheet if necessary.

First Middle Last

2. Give the percentage of ownership or stock owned or to be owned in the small business concern or the Development Company %

Social Security No.

3. Date of Birth (Month, day, and year)

4. Place of Birth (City & State or Foreign Country)

Name and Address of participating lender or surety co. (when applicable and known).

5. U.S. Citizen? YES NO

If no, are you a lawful Permanent resident: YES NO

If no, give alien registration number:

6. Present residence address:

From:

To:

Address:

Home Telephone No. (Include A/C)

Most recent prior address (omit if over 10 years ago):

From:

To:

Address:

Business Telephone No. (Include A/C):

PLEASE SEE REVERSE SIDE FOR EXPLANATIONS REGARDING DISCLOSURE OF INFORMATION AND THE USES OF SUCH INFORMATION.

IT IS IMPORTANT THAT THE NEXT THREE QUESTIONS BE ANSWERED COMPLETELY. AN ARREST OR CONVICTION RECORD WILL NOT NECESSARILY DISQULAIFY YOU; HOWEVER, AN UNTRUTHFUL ANSWER WILL CAUSE YOUR APPLICATION TO BE DENIED.

IF YOU ANSWER “YES” TO 7, 8 OR 9, FURNISH DETAILS ON A SEPARATE SHEET. INCLUDE DATES, LOCATION, FINES, SENTENCES, WHETHER MISDEMEANOR OR FELONY, DATES OF PAROLE/PROBATION, UNPAID FINES OR PENALTIES, NAME(S) UNDER WHICH CHARGED, AND ANY OTHER PERTINENT INFORMATION.

7. Are you presently under indictment, on parole, or probation?

Yes No (If yes, indicate date parole or probation is to expire.)

8. Have you ever been charged with or arrested for any criminal offense other than a minor motor vehicle violation? Include offenses that have been dismissed, discharged, or not prosecuted (All arrests and charges must be disclosed and explained on an attached sheet.)

Yes No

9. Have you ever been convicted, placed on pretrial diversion, or placed on any form of probation, including adjudication withheld pending probation, for

any criminal offense other than a minor vehicle violation?

Yes No

10. I authorize the Small Business Administration Office of Inspector General to request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for programs authorized by the Small Business Act, and the Small Investment Act.

CAUTION: Knowingly making a false statement on this form is a violation of Federal law and could result in criminal prosecution, significant civil penalties, and a denial of your loan, surety bond, or other program participation. A false statement is punishable under 18 USC 1001 by imprisonment of not more than five years and/or a find of not more than $10,000; under 15 USC 645 by imprisonment of not more than two years and/or a fine of not more than $5,000; and, if submitted to a Federally insured institution, under 18 USC 1014 by imprisonment of not more than thirty years and/or a fine of not more than $1,000,000.

Signature

Title

Date

Agency Use Only

11. Fingerprints Waived

Date Approving Authority

Fingerprints Required

Date Approving Authority

Date Sent to OIG

1. Cleared for Processing

Date Approving Authority

13. Request a Character Evaluation

Date Approving Authority

PLEASE NOTE: The estimated burden for completing this form is 15 minutes per response. You are not required to respond to any collection of information unless it displays a currently valid OMB

approval number. Comments on the burden should be sent to U.S.Small Business Administration, Chief, AIB, 409 3rd St., S.W., Washington D.C. 20416 and Desk Officer for the Small Business

Administration, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503. OMB Approval 3245-0178. Please Do Not Send Forms To Omb.

Insurance Information

Collateral Real Estate
Business Name
Property Owner’s Name
Property Owners Address
Type of Property :			Other Explain
Date Purchased	Original Purchase Price			$		Present Value	$
Policy #		Insurance Amount			$
Insurance Carrier

Agent	Phone
Agent Address		City	Zip

Additional comments

Business Asset Insurance

Insurance Carrier
Agent	Phone
Agent Address	City	Zip
Policy #	Insurance Amount	$

Please complete this questionnaire to help us complete your loan application package.

Best Way to contact you:

E-mail Address:

Who will be the full time manager of new store?

What salary will this manager be receiving?

Will you be continuing at your present employment? Salary?

Will your spouse continue work? Salary?

Car Balance: $ monthly payment: $ Is it a lease?

Is there a 2^nd Mortgage or Equity line on house/properties?

What is the Franchise Fee?

How much of the Franchise Fee have you already paid to date?

What will be the estimated Total Project costs for this loan?

Location of Site:

Detailed write-up of site (i.e. Sq. Footage, Residential/Commercial area, type of location/strip mall, name of other stores at location.

How many employees will be working at the new store?

Full time Part time

What will be the hours of operation?

Restaurants Only: # of seats Average # of customers per day

Average ticket sale per person:

What is the projected opening date?

Will you need to relocate to this location?

Will you be buying or renting your home?

Do you own any other Businesses?

Name/type of Business:

What is the value of this company to you?

Do you have a balance on a loan with this business?

Have you or any partners on your loan filed for bankruptcy: Please send letter of explanation.

Amount of Loan Requested

Term: # of Years (requested):

(See Estimated Project Costs Below for Requested Loan Amount)

Applicant Company Information