Economic Development Administration
Loan Program
Date Established
Federal Tax ID
Business Information
Business Applicant
Legal Name
Business Address
City,State, Zip
Contact Name
The purpose of this application is to collect information about the Busine
ss Applicant (“Applicant”) and its
principals, the loan request, indebtedness, information about current
or previous government financing, and
certain other topics.
This form is to be completed by the
Applicant and all individuals identified below and submitted to South
Central Kansas Economic Development District (SCKEDD).
of the requested information is required for SCKEDD to make a determinat
ion regarding
eligibility for financial assistance. Failure to submit the information would affect that determination.
Instructions for completing this Application:
This Application is divided into two sections.
Section I requests information about the Business Applicant and must be comple
ted in its entirety, signed
and dated by an authorized representative of the Business Applicant that is requesting a business loan.
A separate Section I is required to be completed and signed for each co-applicant (e.g. “Eligible Passive
Company (EPC)”or
“Operating Company (OC)”).
Section II
of this form requests information about each of the Business Applicant’s principals. This section
must be completed in its entirety, signed and dated by the following:
For a sole proprietorship, the sole proprietor;
For a partnership, all general partners, and all limited partners owning 20% or more of the
equity of the
firm; or any partner that is involved in management of the applicant business;
For a corporation, all owners of 20% or more of the corporation, and each officer and director;
For limited liability companies, all members owning 20% or more of the company, each officer, director,
and managing member;
Any Person hired by the business to manage day-to-day operations (“key employee”); and
Any Trustor (if the Small Business Applicant is owned by a trust). All parties listed above are considered
“Associates” of the Small Business Applicant as defined in 13 CFR § 120.10, as well as “principals.”
A separate Section II is required to be completed and signed by each principa
l of the Business Applicant. For
clarification regarding any of the questions, please
contact SCK
Phone Number
Purpose of this Application
Required Documents
Please complete the application and send the items below. Your loan application will be reviewed once we
receive the completed, signed application and requested documents below.
Small Business Applicant Ownership
Owner Name Title Ownership % Residential Address
SECTION I: Applicant Business Information
Business Tax R
eturns (Prior
3 years)
Current YTD Business Financial Statements
Copy of Personal Guarantor/Principal Driver's License
Cash Flow Projections for first 12 months
Personal Tax Returns
Business Plan/Management Summary
List all proprietors, partners, officers, directors, and holders of outstanding stock. 100% of ownership must be
reflected. Attach a separate sheet if necessary. Based on this form’s instructions not all owners will need to
complete the Principal Information section of this form.
Business Need Amount Notes
Leasehold Improvements
Furniture and Fixtures
Computers and Office Equipment
Other Capital Purchases
Working Capital (Cash)
Total Business Need
Summary of Business Applicant
Amount Notes
Personal Cash
Business Cash
Other Cash
Total Business Applicant Injection
Loan Amount
Insert total to fund the business start, expansion or purchase. Funds should be final and include the owner's
portion of funds, total loan amount and any investor funding. Any changes need to be sent to our program
Estimated Loan Need
$ 0.00
$ 0.00
$ 0.00
Principal Name
Social Security Number or
Tax ID if an Entity
Date of Birth
Place of Birth
(City & State or Foreign Country)
Home Address Home Phone
% of Ownership in the
Small Business Applicant
Veteran/Gender/Race/Ethnicity data is collected for program reporting purposes only.
Disclosure is voluntary and has no bearing on the credit decision.
Enter Response Below
Veteran 1=Non-Veteran; 2=Veteran; 3=Service-Disabled Veteran; 4=Spouse of Veteran; X=Not Disclosed
Gender M=Male; F=Female; X=Not Disclosed
Race (more than 1
may be selected)
1=American Indian or Alaska Native; 2=Asian; 3=Black or African-American; 4=Native Hawaiian or
Pacific Islander; 5=White; X=Not Disclosed
Ethnicity H=Hispanic or Latino; N=Not Hispanic or Latino; X=Not Disclosed
Unless stated otherwise, if any of the questions below are answered “Yes,” please provide details on a separate sheet.
# Question Yes No
Initial here to confirm your response to question 1
2 Have you been arrested in the last 6 months for any criminal offense?
Initial here to confirm your response to question 2
For any criminal offense other than a minor vehicle violation have you ever: 1) been convicted; 2) pleaded guilty;
3) pleaded nolo contendere; 4) been placed on pretrial diversion; or 5) been placed on any form of parole or probation
(including probation before judgment)?
Initial here to confirm your response to question 3
If you answer
“Yes” to questions 1 or 2, you must complete a “Statement of Personal History.” You will need to furnish details,
including dates, location, fines, sentences, level of charge (whether misdemeanor or felony), dates of parole/probation, unpaid fines
or penalties, name(s) under which charged, and any other pertinent information.
Are you presently suspended, debarred, proposed for debarment, declared ineligible, or voluntarily excluded from
participation in this transaction by any Federal department or agency?
If you are a 50% or more owner of the Small Business Applicant, are you more than 60 days delinquent on any
obligation to pay child support arising under an administrative order, court order, repayment agreement between the
holder and a custodial parent, or repayment agreement between the holder and a state agency providing child support
enforcement services.
6 I am a U.S. Citizen OR I have Lawful Permanent Resident status
Registration Number:
I am not a U.S. Citizen or Lawful Permanent Resident
Country of Citizenship:
Initial here to confirm your responses to question 6
Do you have any ownership in other businesses which would be defined as an Affiliate in the definition found on page
1? (If “Yes,” attach a listing of all businesses and your ownership percentage or position in the business.)
8 Have you, or any business you controlled, ever filed for bankruptcy protection?
9 Are you, or any business you control, presently involved in any legal action (including divorce)?
Have you or any business owned or controlled by you ever obtained a direct or guaranteed loan from EDA or any
other Federal agency or been a guarantor on such a loan? (This includes student loans.)
(a) If you answered “Yesto Question 10, is any of the financing currently delinquent?
(b) If you answered “Yes” to Question 10, did any of this financing ever default and cause a loss to the
(If Yes to (a) or (b) above, please provide Lender with a written explanation.)
Business Name:
This form needs to be filled out by all persons owning 20% or more of the operating company and borrowing entity.
SECTION II: Principal Information
Are you presently subject
to an indictment, criminal information, arraignment, or other means by which formal
criminal charges are brought in any jurisdiction?
Home Address
City, State, Zip
Phone Number
Cash on Hand
Savings Acct
Accounts Receivable
Life Insurance
Stocks & Bonds
Real Estate
Personal Property
Other Assets
Total Assets
Accounts Payable
Notes Payable
Installment Account (Auto)
(Auto) Monthly Payment
Installment Account (Other)
(Other) Monthly Payment
Loans Against Life Insurance
Mortgages on Real Estate
Unpaid Taxes
Other Liabilities
Total Liabilities
Net Worth
Sources of Income
Net Investment Income
Real Estate Income
Other Income
Contingent Liabilities
As Endorser or Co-Maker
l Claims & Judgments
Provision for Fed. Income
r Spe
cial De
The personal financial statement needs to be filled out by all persons owning 20% or more of the operating
company and borrowing entity.
Business Name
of Employer
$ 0.00
Description - Show
Manufacturer, Model,Serial
Amount of
Name of
Commercial Real Estate
Amount of
Lien Name of Lienholder
Name of Creditor
Current or
Delinquent Maturity Date
Business Debt Schedule
Machinery and Equipment
Unpaid Taxes (Describe in detail as to type, to whom payable, when due, amount, and what property, if any, a tax lien
ATTACHMENT: Business Debt Schedule
List all Real Estate, Machinery and Equipment assets to be used as security for this loan.
All machinery a
nd equipment greater than $5,000 must show; manufacturer or make, model, year, and serial
Items with no serial number must be
clearly identified (use additional sheet if more space is
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
I/we hereby authorize South Central Kansas Economic Development District, Inc., (hereafter referred to as
“CDCCertified Development Company) or any of its affiliates to make all inquiries it deems necessary to verify the
accuracy of the information provided herein, and to determine my/our credit worthiness for any purpose related
to our credit transaction with them. I/we hereby certify that the enclosed application information including
attachments/exhibits are valid and correct to the best of my/our knowledge.
I/we hereby authorize the CDC to furnish relevant information to all necessary sources including various federal,
state, county, and conventional funding opportunities to obtain the best sources for the project. I/we hereby authorize
the CDC to furnish relevant information to CDC’s Loan Review Committee(s) for decision; and, to furnish
relevant information to the CDC’s Board of Directors and various federal, state, and county agencies, officials and
economic development representatives for CDC’s reporting requirements regarding area economic development.
I/we authorize any company, partnership, corporation, organization or entity of whatever kind to provide the
CDC with any credit, financial or personal information held by such entity and requested by the CDC.
I/we further agree that I shall indemnify and hold the CDC harmless from any claim or cause of action
arising because of incorrect, inaccurate or incomplete information furnished by me, whether the furnishing of such
incorrect, inaccurate or incomplete information was accidental or intentional and in consideration of the CDC’s
assistance, I waive all claims against the CDC, its personnel or counselors arising from this assistance.
The small business applicant and its principals as individuals, agree to indemnify and hold South Central Kansas
Economic Development District, Inc. (CDC) and/or its agents and assigns harmless from and against, any damages, cost,
liability or expense attributable to release, threatened release, discharge, manufacture, production, storage or disposal
or the presence of hazardous toxic substances, on or under borrower’s property or property in which borrower has
an interest including adjoining real property and based upon claims assertible by local, state, and federal
governmental authority or other third parties against CDC or its assigns.
This indemnification will specifically survive, and is entirely independent of the debtor’s contractual obligation to
repay the primary obligation held by CDC as amended, extended, or renewed by CDC, prepayment in full of the
borrower’s indebtedness to CDC; and release of CDC liens on borrower’s real or personal property by payment,
foreclosure, or other action including CDC’s discretionary abandonment of lien.
Print Name
Print Name
Social Security No.
Social Security No.
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