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Commercial/Residential Real Estate
Loan Mod/Foreclosure Defense
Short Sale
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Bridge Loan
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Bankruptcy
Bankruptcy Ch 7
Bankruptcy Ch 13
Deed in Lieu
Forensic Audit
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HAMP Modification
HOME Report
2nd Lien Modification
Loan Modification
Loss Mitigation
Securitized Audit
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HAFA Short Sale
Short Sale
Subject Property Details
1) Subject Property Details
Is this the main subject property?
Property Location
Subject Address
Subject Unit#
Subject City
Subject State
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Subject Zip Code
Subject Country
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United States
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the Congo
Cook Islands
Costa Rica
Cote D Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic Peoples Republic of
Korea, Republic of
Kosovo
Kuwait
Kyrgyzstan
Lao Peoples Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, the Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.s.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
County
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MSA
Property Characteristics
Subject Property Type
---Residential---
Single Family Home
Condo
Condo Low Rise
Condo High Rise
Loft
TownHouse
SRO
Manufactured
Duplex
3 Units
4 Units
2-4 Units
Lot/Land
Residential Portfolio
AirBnB
---Commercial---
Affordable Housing
Apartment Complex
Assisted Living Facility
Auto Repair
Bed & Breakfast
Bio-Energy
Boathouse
Car Wash
Church
Co-Op
Commercial Lot/Land
Condotel
Construction
Daycare
Developed Land
Equipment
Fractured Co-op
Fractured Condo
Funeral Homes
Garage/Storage
Gas Stations
Hospital
Hotel
Infrastructure
Laundromat
Light Industrial
Medical Cannabis
Mixed Use
Motel
Multi-Family-5+
Mobile Home Park
Medical Office
New Residential Development
Owner Occupied Business
Office Building
Public Safety
PUD
Recreational Properties
Renewable Energy
Resorts
Restaurant/Bar
Retail
Self-Storage
Solar
Special Purpose Properties
Strip Mall
Student Housing
Tavern
Underlying Co-op
Warehouse
Wastewater Treatment
Water Treatment
Other
Condo Eligibility
Warrantable
Non Warrantable
Property Details
Zillow value
$
Get Zillow Value
Price Per Door
$
Subject Present Occupancy
- Select -
Vacant
Rented
Tenant Occupied
Deliquent Renter
Deliquent Owner
Owner Occupied
FHA Secondary Residence
Seller Occupied
Can we obtain interior access?
Yes
No
Relationship
Property Manager
Tenant
Real Estate Agent
Seller
Borrower
Other
Relationship
Rent Roll
Rent Roll
1
Tenant Name
Unit Type
Residential
Commercial
Unit #
Sq Ft
Bedroom
Bath
Half Baths
Lease Start Date
Lease End Date
Date of Last Rent Increase
Lease Payment Frequency
Annual
Month-To-Month
Short-Term Rental
Other
Lease Extension End Date
Move in Date
Preliminary Estimated Rents
$
Preliminary Rent Source
Actual Rents
Borrower Estimated Rents
Market Rents
Market Rents
$
120% Market Rents
$
Market Rent Source
RentRange
HouseCanary
RentCast
1007
Actual Rents
$
Lease Validation
Actual Rents
Market Rents
120% Market Rents
Monthly Rent
$
Subsidized
Yes
No
Vacant
Yes
No
Section 8
Yes
No
Comments
File Upload
Add New Rent Roll Entry
Property Flood Certificates
Property Flood Certificates
1
Is Building in a Special Hazard Zone
Yes
No
Flood Zone
X
D
C
B
A
AE
A1-30
AH
AO
AR
A99
V
VE
V1-30
Flood Certificate Company
Date of Determination
NFIP Map Number or Community Panel Number
NFIP Map Panel Effective/Revised Date
Flood Certificate Number
Notes
NFIP Non-Participating
Add New Property Flood Certificates Entry
Appraisers information
Appraiser
1
Appraiser First Name
Appraiser Last Name
Email
*
Appraiser Company
Phone
As Is Value
$
Rehabbed Value
$
Monthly Rent
$
Job Types
As Is
As Complete
As Complete / Stabilized
Insurable Value
Other
Date Obtained
Requested Return Date
Rush Order
Yes
No
N/A
Order Date
Comments
Upload Appraisal
Appraisal Effective Date
Appraisal Inspection Date
Expected Delivery Date
Expected Delivery Delay #
Add New Appraiser Entry
HOA information
is there a HOA?
Yes
No
Are HOA fees paid current?
Yes
No
Monthly HOA Fees
$
Delinquency Total?
$
Contact Name
Email
HOA Company Name
Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZipCode
Contact Phone #
Fax #
Does HOA Allow Rentals
Yes
No
Is AirBnb Allowed
Yes
No
HOA applies to all properties
Yes
No
Is Community 55+?
Yes
No
Notes
Is there a Master/Secondary HOA/COA?
Yes
No
Amount
$
Contact Name
Email
HOA Company Name
Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Notes
Subject Property
Present Occupancy
- Select -
Owner Occupied
Owner Occupied/Vacant
2nd Home
Non-Owner with Tenant
Non-Owner/Vacant
Are taxes escrowed?
Is Insurance escrowed?
Home value? (As-Is)
$
Borrower Info
First Name
Middle Name
Last Name
Borrower Email
Please Wait...
Secondary Email
Home Phone
Cell Phone
Fax
Cell Carrier
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AllTel
ATT
Cingular
Cricket
H20
Metro PCS
Boost Mobile
Nextel
Sprint PCS
Straight Talk
T-Mobile
Tracfone
US Cellular
Virgin Mobile
Verizon
Preferred Communication
Phone
E-mail
Text
Web Portal
Is there a Co-borrower?
Alt. Phone #
Work Phone #
Address
Unit #
City
State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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Hawaii
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Indiana
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
County
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Country
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United States
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the Congo
Cook Islands
Costa Rica
Cote D Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic Peoples Republic of
Korea, Republic of
Kosovo
Kuwait
Kyrgyzstan
Lao Peoples Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, the Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.s.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Borrower Type/Entity Info
Borrower Type
- Select -
Individual
Entity
Trust
Retirement Entity
Trust Type
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Revocable
Irrevocable
Retirement Entity
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Self-Directed IRA
Self-Directed 401K
IRA LLC
General Business Info
Entity Name
Trade Name/DBA
Entity Type
- Select -
Sole Proprietorship
Limited Partnership
General Partnership
LLC
Corp
S-Corp
Self Employed-1099 Contractor
501 (c)(3) Nonprofit
501 (c)(19) Veterans Org
Tribal Business
Trust
Joint Venture
Estate
Other
Date Of Formation
Time in Business
Less than 3 Months
3-6 Months
6-12 Months
1-2 Years
2-3 Years
3-5 years
5+ years
State Of Formation
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
States Registered In
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Federal Tax ID/EIN
Business License Number
Issuance Date
Expiration Date
State Issued
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Other States Operating In
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
DBA Name(s)
Prior Business Name(s)
Organizational Ref #
Business Phone
Website Address
Business Address
Start Date at Location
Address
City
State
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Is the billing address the same as above?
Billing Address
Billing City
Billing State
-Select-
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Billing Zip Code
Location
Urban
Rural
Suburban
Property Ownership
- Select -
Own
Rent
Value of Property?
$
Total Debt on Property?
$
Name of Lender(s)?
Landlord/Mortgage Contact Name
Landlord/Mortgage Phone
Rent/Mortgage Payment
Business Details
Business Type
- Select -
Mobile & E-Commerce
Retail
Home Improvement
Food & Beverage
Travel and Tourism
Transportation
Meetings and Events
Education
B2B
Healthcare
Government
Non-Profit
Entertainment
Lodging
Legal
Salon & Spas
Professional Services
Other
# of employees currently
# of employees after loan
Business Category
- Select -
Agriculture,Forestry,Fishing
Construction
Manufacturing
Transportation & Public Utilities
Whole Sale Trade
Retail Trade
Finance Insurance Real Estate
Services
Public Administration
Utilities
Transportation and Warehousing
Professional, Scientific,Tech Services
Educational Services
Health Care and Social Assistance
Arts,Entertainment,Recreation
Restaurant,Internet,Mail Order/Telephone Order
Type of product or service sold
Naics Code
NAICS Code look up
Does your business sell a
Service
Product
Is your Business
B2B
B2C
Is your business home based?
Yes
No
Do you take credit card payments?
Yes
No
Terminal/ POS Make/Model
How many card processor banks do you have active?
Merchant Processing Bank Name(s)
Do you charge sales tax?
Yes
No
How are employees paid?
- Select -
W-2
1099
W-2 & 1099
Cash
Do you have more than one business location?
Yes
No
How many locations?
Other Location Details & Addresses
Is the business a franchise?
Yes
No
Name of Franchise
Point of Contact
Point of Contact Phone
Point of Contact E-mail
Website for Franchise
is your business seasonal?
Yes
No
if Yes, what are the peak months?
Business Description
Do you have Business Reference(s)?
Yes
No
1
)
Phone Name
Company
Fax
Email
Business Financials
Average Monthly Credit Card Sales
$
Average Monthly Deposits
$
Annual Revenue
$
Annual Gross Profit
$
YTD-Net Business Income
$
Date of Operating Agreement
Gross Annual Revenues $
$
Gross Income Last Year
$
Net Income Last Year
$
Gross Income 2 years ago
$
Net Income 2 years Ago
$
Average Bank Balance
$
Has business ever filed for bankruptcy?
Yes
No
Status of Business Bankruptcy
Still Active
Discharged- 1 month
Discharged- 1-3 months
Discharged- 3-6 months
Discharged- 6-12 months
Discharged-1 year
Discharged- 2 years
Discharged- 3 years
Discharged- 5 years
Discharged-7+ years
Recent NSFs
0
1
2
3
4
5
6
7
8
9
10+
Does your business owe taxes for years prior to the current year?
Yes
No
Estimated amount owed
$
Members/Officers
(List all members with 20% ownership or more.)
Same as Borrower/Applicant Info Above
Name
Title
% of Ownership
%
Annual Salary/Compensation
Address
Phone
Cell
SSN
DOB
Credit Score
Email
Drivers License State
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Drivers License
Member TIN
Personal Guarantee for this loan
Yes
No
Authorized signer for making loans
Yes
No
Citizenship
U.S. Citizen
Perm Resident
Non-Perm Resident
Name
Title
% of Ownership
%
Annual Salary/Compensation
Address
Phone
Cell
SSN
DOB
Credit Score
Email
Drivers License State
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Drivers License
Member TIN
Personal Guarantee for this loan
Yes
No
Authorized signer for making loans
Yes
No
Citizenship
U.S. Citizen
Perm Resident
Non-Perm Resident
Name
Title
% of Ownership
%
Annual Salary/Compensation
Address
Phone
Cell
SSN
DOB
Credit Score
Email
Drivers License State
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Drivers License
Member TIN
Personal Guarantee for this loan
Yes
No
Authorized signer for making loans
Yes
No
Citizenship
U.S. Citizen
Perm Resident
Non-Perm Resident
Name
Title
% of Ownership
%
Annual Salary/Compensation
Address
Phone
Cell
SSN
DOB
Credit Score
Email
Drivers License State
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Drivers License
Member TIN
Personal Guarantee for this loan
Yes
No
Authorized signer for making loans
Yes
No
Citizenship
U.S. Citizen
Perm Resident
Non-Perm Resident
Name
Title
% of Ownership
%
Annual Salary/Compensation
Address
Phone
Cell
SSN
DOB
Credit Score
Email
Drivers License State
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Drivers License
Member TIN
Personal Guarantee for this loan
Yes
No
Authorized signer for making loans
Yes
No
Citizenship
U.S. Citizen
Perm Resident
Non-Perm Resident
Name
Title
% of Ownership
%
Annual Salary/Compensation
Address
Phone
Cell
SSN
DOB
Credit Score
Email
Drivers License State
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Drivers License
Member TIN
Personal Guarantee for this loan
Yes
No
Authorized signer for making loans
Yes
No
Citizenship
U.S. Citizen
Perm Resident
Non-Perm Resident
Name
Title
% of Ownership
%
Annual Salary/Compensation
Address
Phone
Cell
SSN
DOB
Credit Score
Email
Drivers License State
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Drivers License
Member TIN
Personal Guarantee for this loan
Yes
No
Authorized signer for making loans
Yes
No
Citizenship
U.S. Citizen
Perm Resident
Non-Perm Resident
Name
Title
% of Ownership
%
Annual Salary/Compensation
Address
Phone
Cell
SSN
DOB
Credit Score
Email
Drivers License State
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Drivers License
Member TIN
Personal Guarantee for this loan
Yes
No
Authorized signer for making loans
Yes
No
Citizenship
U.S. Citizen
Perm Resident
Non-Perm Resident
Name
Title
% of Ownership
%
Annual Salary/Compensation
Address
Phone
Cell
SSN
DOB
Credit Score
Email
Drivers License State
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Drivers License
Member TIN
Personal Guarantee for this loan
Yes
No
Authorized signer for making loans
Yes
No
Citizenship
U.S. Citizen
Perm Resident
Non-Perm Resident
Name
Title
% of Ownership
%
Annual Salary/Compensation
Address
Phone
Cell
SSN
DOB
Credit Score
Email
Drivers License State
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Drivers License
Member TIN
Personal Guarantee for this loan
Yes
No
Authorized signer for making loans
Yes
No
Citizenship
U.S. Citizen
Perm Resident
Non-Perm Resident
Add More Members/Officers Info
Corporate Secretary Name
Notes
Sales Method
Retail Swiped
%
KEYED
%
ECOMM
%
MOTO
%
Fee Schedule
Visa/MasterCard/Discover/AXP Qualified Credit Card Discount Rate(for Tiered/Flat) %
%
Visa/MasterCard/Discover/AXP Qualified Credit Card Pass Thru I/C Plus
Qualified Check Card Discount Rate (for Tiered/Flat)
%
Qualified Check Card PassThru I/C Plus
Visa/MasterCard/Discover/AXP
$
Authorization Fee
$
Monthly Program Fee "Cash Discount"
$
Customer Service Fee
$
Monthly Minimum Fee
$
PIN Debit Transaction Fee
$
Batch Fee
$
Amex OPT Blue Qualified Rate
%
Amex OPT Blue Mid Qual
%
Amex OPT Blue Non Qual
%
Amex OPT Blue Pass Thru I/C Plus
Amex ESA #
AVS Transaction Fee
$
EBT Transaction Fee
$
EBT Account#
Amex Processing Fee
%
Other Fee
$
3 Tier Pricing Visa/MC/Disc/AXP Mid Qual
%
3 Tier Pricing Visa/MC/Disc/AXP Non Qual
%
Chargeback Fee
$
ACH Retrieval Fee
$
Equipment Info
Are you currently using a point of sale system?
Yes
No
Software
Software Version
Does your Business have a Land Line?
Yes
No
How will your new terminal connect to the internet?
--select--
WiFi
Ethernet
Telephone Land Line
Mobile Unit with Built in Cellular
Does your business location(s) have internet?
Yes
No
Do you have WiFi?
Yes
No
Do you know the password?
Yes
No
What is your Wifi password?
Do you expect your EBT?
Yes
No
What is your EBT number?
What would you like to have printed on the bottom of the receipt?
Is the equipment for a restraunt?
Yes
No
Do you want Tips Added On?
Yes
No
Do you want the customer to fill out Tip on Receipt or at cashier when they checkout only?
--select--
On Receipt
At Checkout Only
Suggested % #1
%
Suggested % #2
%
Suggested % #3
%
Do you want your Terminal to automatically Batch out? (Not recommended for restraunts. Once it batches out, unentered Tips will be lost).
Yes
No
At What Time?
Shipping Address
Shipping City
Shipping State
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Shipping Zip Code
Borrower Background
Are you a U.S. Citizen?
Yes
No
Origin
Visa Status
Has the borrower been declared bankrupt within the past 7 years?
Yes
No
Status of Personal Bankruptcy
Still Active
Within 1 month
1-3 months
3-6 months
6-12 months
1 year
2 years
3 years
5 years
7+ years
If Yes, identify the types of bankruptcy
Chapter 7
Chapter 11
Chapter 12
Chapter 13
Please provide filing date, current status, properties included, etc...
Are there any outstanding judgments against the borrowers?
Yes
No
(If Yes, Provide explanation below.)
Do you have any active lawsuits against you?
Yes
No
(If Yes, Provide explanation below.)
Have you had or currently have any property tax liens?
Yes
No
(If Yes, Provide explanation below.)
Has the borrower directly or indirectly been obligated on any loan which resulted in foreclosure, transfer of title in lieu of foreclosure, or judgement?
Yes
No
Status of Foreclosure
Still Active
Within 1 month
1-3 months
3-6 months
6-12 months
1 year
2 years
3 years
5 years
7+ years
(If Yes, Provide explanation below.)
Is the borrower presently delinquent or in any default on any Federal debt or any other loan, mortgage, financial obligation, bond, or loan guarantee
Yes
No
(If Yes, Provide explanation below.)
Have you ever been convicted of a felony or other fraud related crimes?
Yes
No
(If Yes, Provide explanation below.)
Are you in a Civil Union or a Domestic Partnership, or do you have a non-borrowing spouse, or are you a party to a Designated Beneficiary Agreement?
Yes
No
(If Yes, Provide explanation below.)
Within the past 7 years, have you completed a pre-foreclosure sale, whereby the property was sold to a third party and the Lender agreed to accept less than the outstanding mortgage balance due?
Yes
No
Have you had property foreclosed upon in the last 7 years?
Yes
No
Have you previously had a short sale?
Yes
No
When was the short sale?
Please explain the circumstances of the short sale
Background Explanation
Income tax returns filed through
Are any returns currently being audited or contested?
Yes
No
what years (s)
Have you drawn a will?
Yes
No
Please furnish the name of the executor(s) and year will was drawn
Have you ever had a financial plan prepared for you?
Yes
No
Is there a line of credit or unused credit facility at any other institution(s)?
Yes
No
Please indicate where, how much, and name of banker
Do you anticipate any substantial inheritances?
Yes
No
Please Explain
SBA Questions
$
$
Purpose of the loan:
Payroll
Rent/Mortgage Interest
Utilities
Other
Detailed Explanation
Is the Applicant (if an individual) or any individual owning 20% or more of the equity of the Applicant subject to an indictment, criminal information, arraignment, or other means by which formal criminal charges are brought in any jurisdiction, or presently incarcerated, or on probation or parole?
Yes
No
Detailed Explanation
Have you been arrested in the past six months for any criminal offense?
Yes
No
Detailed Explanation
Within the last 5 years, for any felony, has the Applicant (if an individual) or any owner of the Applicant 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 judgement)?
Yes
No
Detailed Explanation
Has an application for the loan you are applying for now ever been submitted to SBA or to a Certified Development Company or lender in connection with any SBA program?
Yes
No
Detailed Explanation
Is the Applicant a franchise that is listed in the SBAs Franchise Directory?
Yes
No
Detailed Explanation
Does the Small Business Applicant have any Affiliates?
Yes
No
Detailed Explanation
Has the Small Business Applicant and/or its Affiliates ever filed for bankruptcy protection?
Yes
No
Still Active
Within 1 month
1-3 months
3-6 months
6-12 months
1 year
2 years
3 years
5 years
7+ years
Detailed Explanation
Is the Small Business Applicant and/or its Affiliates presently involved in any pending legal action?
Yes
No
Detailed Explanation
Is the Applicant or any owner of the Applicant presently suspended, debarred, proposed for debarment, declared ineligible, voluntarily excluded from participation in this transaction by any Federal department or agency, or presently involved in any bankruptcy?
Yes
No
Detailed Explanation
If you are at least a 50% or more owner of the applicant business, 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? .
Yes
No
Detailed Explanation
Has the Small Business Applicant and/or its Affiliates ever obtained a direct or guaranteed loan from SBA or any other Federal agency or been a guarantor on such a loan?
Yes
No
Is any of the financing currently delinquent?
Yes
No
Detailed Explanation
Did any of this financing ever default and cause a loss to the Government?
Yes
No
Detailed Explanation
Are any of the Small Business Applicants products and/or services exported or is there a plan to begin exporting as a result of this loan?
Yes
No
Provide the estimated total export sales this loan will support:
$
Is the Small Business Applicant using (or intending to use) a packager, broker, accountant, lawyer, etc. to assist in (a) preparing the loan application or any related materials and/or (b) referring the loan to the lender?
Yes
No
Detailed Explanation
Are any of the Small Business Applicants revenues derived from gambling, loan packaging, or from the sale of products or services, or the presentation of any depiction, displays or live performances, of a prurient sexual nature?
Yes
No
Detailed Explanation
No SBA employee, or the household member (see definition on page 1) of an SBA employee, is a sole proprietor, partner officer, director, or stockholder with a 10 percent or more interest, of the Applicant.
Yes
No
Detailed Explanation
No former SBA employee, who has been separated from SBA for less than one year prior to the request for financial assistance, is an employee, owner, partner, attorney, agent, owner of stock, officer, director, creditor or debtor of the Applicant.
Yes
No
Detailed Explanation
No member of Congress, or an appointed official or employee of the legislative or judicial branch of the Federal Government, is a sole proprietor, general partner, officer, director, or stockholder with a 10 percent or more interest, or household member of such individual, of the Applicant.
Yes
No
Detailed Explanation
No Government employee having a grade of at least GS-13 or higher is a sole proprietor, general partner, officer, director, or stockholder with a 10 percent or more interest, or a household member of such individual, of the Applicant
Yes
No
Detailed Explanation
No member or employee of a Small Business Advisory Council or a SCORE volunteer is a sole proprietor, general partner, officer, director, or stockholder with a 10 percent or more interest, or a household member of such individual, of the Applicant.
Yes
No
Detailed Explanation
Have you, or any business you controlled, ever filed for bankruptcy protection?
Yes
No
Detailed Explanation
Is the United States the principal place of residence for all employees of the Applicant included in the Applicants payroll calculation above?
Yes
No
Detailed Explanation
Do any of your employees earn more than $100,000/year?
Yes
No
If Yes, Did you calculate your estimated monthly payroll using the cap of 100,000 per employee?
Detailed Explanation
Has the Applicant, any owner of the Applicant, or any business owned or controlled by any of them, ever obtained a direct or guaranteed loan from SBA or any other Federal agency that is currently delinquent or has defaulted in the last 7 years and caused a loss to the government?
Yes
No
Detailed Explanation
Are you, or any business you control, presently involved in any legal action (including divorce)?
Yes
No
Detailed Explanation
Has the Business received an SBA Economic Injury Disaster Loan between January 31, 2020 and April 3, 2020?
Yes
No
Loan Amount
$
Detailed Explanation
Yes
No
Detailed Explanation
Other Business/Affiliate Information
Company Name
Tax Id/EIN #
Legal Owners/Title/Ownership %
# of employees
Years in Business
Has applied for SBA loans?
Yes
No
Description
Add Other Business Info
How many W-2 Employees do you have?
How many W-2s did you issue for 2020?
When was your company started?
-Select-
Before Jan 1, 2019
Between Jan 1, 2019 – Feb 15, 2020
After Feb 15, 2020
Did you operate under full or partial suspension due to government order?
No
Partial Suspension
Full Suspension
How your business was impacted during the partial or full shutdown
What quarters were you affected? (If not sure leave blank)
Q1 2020: (after the CARES Act took effect: March 13 - March 31, 2020)
Q2 2020: Apr – Jun
Q3 2020: Jul – Sep
Q4 2020: Oct – Dec
Q1 2021: Jan – Mar
Q2 2021: Apr – Jun
Q3 2021: Jul – Sep
Q4 2021: Oct – Dec
Please provide gross receipts of each quarter excluding any PPP funds if they are included as revenue
Q1 2019
$
Q2 2019
$
Q3 2019
$
Q4 2019
$
Q1 2020
$
Q2 2020
$
Q3 2020
$
Q4 2020
$
Q1 2021
$
Q2 2021
$
Q3 2021
$
Q4 2021
$
Did any of your vendors operate under full or partial suspension due to government order that affected your ability to do business?
No
Partial Suspension
Full Suspension
Not Sure
How your business was impacted during the partial or full shutdown
What quarters were you affected due to vendor delays
Q1 2020: (after the CARES Act took effect: March 13 - March 31, 2020)
Q2 2020: Apr – Jun
Q3 2020: Jul – Sep
Q4 2020: Oct – Dec
Q1 2021: Jan – Mar
Q2 2021: Apr – Jun
Q3 2021: Jul – Sep
Q4 2021: Oct – Dec
Please provide gross receipts of each quarter excluding any PPP funds if they are included as revenue
Q1 2019
$
Q2 2019
$
Q3 2019
$
Q4 2019
$
Q1 2020
$
Q2 2020
$
Q3 2020
$
Q4 2020
$
Q1 2021
$
Q2 2021
$
Q3 2021
$
Q4 2021