Fillable MICROENTERPRISE BUSINESS LOAN REQUEST FORM SECTION 1: PERSONAL

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MICROENTERPRISE BUSINESS LOAN REQUEST FORM SECTION 1: PERSONAL

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1
MICROENTERPRISE BUSINESS LOAN REQUEST FORM
SECTION 1: PERSONAL INFORMATION
Name (Last, First)_________________________________________________________________
Permanent home address:______________________________________________________________________________
Number and Street Apt #
___________________________________________________________________________________________________
City State Country Zip Code
Home Telephone ____________________ Business Telephone _____________________
Mobile Telephone ________________________ Fax number _____________________________
E-mail address: _______________________________________ Web Address:__________________________________
Ethnicity: Asian African American Other
Native Hawaiian/Pacific Islander Caucasian Hispanic/Latino
Gender: Female Male Social Security # ___________________
Date of Birth (M/D/Year) ____/____/_______ Place of Birth (pick from dropdown menu) _____________________
If not born in the U.S - Date of Arrival in U.S.(M/D/Year): ___ /___/______
If an immigrant, Immigration Status Upon Entry to U.S: Refugee Parolee Tourist visa Green card Asylee
Marital Status (check one): Single Married Divorced Separated Widowed
Number of Children/Dependents and their age: _________________________Total number of people in household: _____
Employment Status: FT Self Employed FT Employed Seasonal Employed
(FT > 35 hours/week)
PT Self Employed PT Employed Unemployed
Current Occupation: ____________________ Last year’s annual gross income $ ___________________
Spouse Name:__________________________________________ Date of Birth (M/D/Year) ____/____/_______
Social Security # __________________ _ Mobile Telephone ________________________
675 Third Ave, Suite 1905
New York, NY 10017
Phone: (212) 687-0188
Fax: (212) 682-1120
Email: info@hfls.org
www.hfls.org
Albania
2
Spouse’s Occupation: ____________________ Spouse’s annual gross income $ ___________________
How did you learn about the Microenterprise Loan Program?
Newspaper Name of Newspaper ____________________________________
Family or Friends UJO Mishkan Yecheskel CHYE Other_________________________
Education/Training in the US (Please list programs/degrees and dates):

Name of school Degree Dates (from M/Year to M/Year)
a)
b)
c)
Employment History (Please list all places of employment and dates for the last five years)
Position Employer Dates (from M/Year to M/Year)
a)
b)
c)
Source of Health Insurance: Business Private Medicaid Medicare
Spouse's Employer Employer State-No Cost
Please describe the health insurance coverage for your household:
All members insured Some members insured No members insured
Entitlements: Medicaid Food Stamps ($ ) HEAP WIC Child Care Vouchers
Other (please describe)
How much did you save last year? $______________________ Do You Own a House/ Apartment? Yes No
If Yes, What is its current value? $ ____________________ Date of purchase (M/Year) ____/____/_____
Purchase Price $__________________________ What is the Balance on Your Mortgage? $_______________________
Monthly payment: $__________________
Do you rent? Yes No If Yes, how many bedrooms? ________ Monthly rent: $_________________
Section 8 Yes No
Please list your history of other loans or debt (e.g. education, equipment lease, bank loans & credit card, friends & family)
Type of loan Amount of loan Outstanding balance payment ($ per ) interest rate
3
SECTION 2: BUSINESS INFORMATION
Important Instructions to filling out Section 2, please read before proceeding further:
Section 2 helps us evaluate your plan for launching a new or expanding an existing business. If you are not yet in business
some of the questions below will not apply to you. We understand that you might not have all the requested information.
Answer only those questions you can to the best of your ability. Please write or type in English
All written and oral information disclosed or provided by the applicant to the Hebrew Free Loan Society (“HFLS”)
under this agreement is strictly confidential and will not be disclosed to any third party.
Are you going to:
START EXPAND or PURCHASE a business? (Check one)
If already in business, date formed_____/_____/______ and date purchased (if applicable): ______/______/________
Business Name: ____________________________________________________________________________________
Business Address:____________________________________________________________________________________
Number and street City
___________________________________________________________________________________________________
State Zip Code
A. BUSINESS DESCRIPTION
Is this business full-time or part-time? (FT > 35 hours/week) FT PT Seasonal
Please provide a description of your business or business idea below. Describe your product or service
B. CUSTOMER
Please describe your target or actual customers (age, gender, ethnicity, income, profession, etc.)
C. MARKET
Who is your competition and how are you different (e.g., price, location, hours open, quality of product)?
4
How do you market your product or service? Do you have a formal marketing plan? (If “yes”, please attach)
Please provide average price for your product or service?
Please provide a % breakdown of what region or towns your customers come from (e.g., Manhattan, Brooklyn,
outside of New York state, etc.)?
D. OWNERSHIP
Was the business registered with the New York State? Yes No On what date? ___/____/________
Are you the original owner of this business? Yes No If “yes,” when did this business start? ___/___/_____
If purchased, for what price? $____________________
Do you have business partners? Yes No Are they family members? Yes No
Do you have a partnership agreement among the partners? Religious Civil No
What % does each partner own? ________________________
E. OPERATIONS
What is your role in the business?
What hours and days is the business open?
Do you have a lease? Yes No If yes, are you the primary lessee or are you sub-leasing?
5
What is the term of your lease and what is the size of your location in square feet?
Do you have paid employees or independent contractors? Yes No
If Yes, total number of paid employees in last 12 months: (FT>35 hrs/wk)
Full-Time:______ Part-Time:_______ Seasonal/ Temporary: _______ Independent Contractors:________
Do your family members work in the business?
Do you have a bookkeeper for your business? Yes No If yes, who?____________________________
What Federal/State/City licenses and permits do you need to operate your business? Do you have these permits or
licenses?
F. FINANCIAL INFORMATION
How much in total capital was invested to start this business? $________________________________
What are the average yearly or monthly gross sales of the business? What is the yearly or monthly net profit of the
business? If a start up, please list planned numbers.
In the last year, did you take money out of your business for personal expenses? How much was taken out?
How do you plan to use a loan of up to $25,000? Please list all the uses of this loan. Is this the total amount of
capital you need to meet your business needs? If not, how much more do you need?
6
Have you tried obtaining a business or a personal loan from a bank for your business needs? If you were declined,
please provide the reasons below. If you were offered a loan what are the terms?
G. BUSINESS RISKS
All businesses face risks. Please list specific risks your business faces (e.g., competition, supplier, government
regulations, etc.)?
H. BUSINESS SERVICES
Do you have a formal business plan? Yes No
SECTION 3: APPLICANT DECLARATION
Representations: I hereby certify that the information furnished herein is true and correct.
Credit Reports and Verification: By signing below, you authorize us to obtain a credit report on you. If you ask,
we will tell you if a report has been obtained and the name and address of the agency furnishing the report. You
also agree to verify any information given in this application or on the credit report, as well as provide any
additional information requested in the vetting process by the HFLS staff.
Signature: Date:
Print Name:
Spouse’s Signature: Date:
Print Name:
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MICROENTERPRISE BUSINESS LOAN REQUEST FORM SECTION 1: PERSONAL

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Completed 15 December 2020

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