Which loan program are you applying for? Step Loan Program Small Business Loan Program Small Business First Program Luzerne County Flood Recovery Loan Program

1. Business Information

Business Name*

County*

Mailing Address*

City*

State*

Zip*

Number of Business Owners (20% ownership or more)*

Products/Services Sold

Do you have less than 100 Employees?

Yes     No

Business Phone*

How Long have you owned this business?

Years Months

Cell Phone

E-mail*

Avg Monthly Sales

Avg Monthly Expenses

Does your business deal with any of the following: lending, gambling, firearms, adult oriented products/services, multi-level marketing, speculative real estate?

Yes    No

2. Loan Request

Amount Requested* Are you willing to accept less?*  Yes No
If yes what is the minimum amount you will accept?
How did you hear about MetroAction? Small Business Development Center Chamber of Commerce Small Business Administration Government Agency Internet / Website Newspaper TV Radio Family / Friend Brochure Bank Other
Do you have someone, not living in the same household as the applicants, who can co-sign for this loan? Yes No
*Co-signers should have good credit and cannot live in the same household as the applicant(s). Contact MetroAction to obtain required co-signer documentation.

3. Collateral

In most cases, collateral is required as security for each loan request. Please include values for all sources of collateral that are available. Providing incomplete information will delay processing.

Real Estate Address

Date Purchased Purchase Price  Current Market Value

Amount Owed # Mortgages

Vehicle/Equip (Make, Model, Year)

VIN Mileage Condition Market Value

Amount Owed Pledged for another loan? Yes No

Vehicle/Equip (Make, Model, Year)

VIN Mileage Condition Market Value

Amount Owed Pledged for another loan? Yes No

Whole Life Insurance
(Insurer's Name)

Face Value Cash Value Pledged for another loan? Yes No (Do not include term life insurance policies)

Stocks/Bonds/Securities Description

Market Value Valuation Date Pledged for another loan? Yes No (Do not include retirement accounts)

Business Assets Description

Market Value Valuation Date Pledged for another loan? Yes No

4. Personal Information

Each person who owns 20% or more of the business MUST complete this application. If there is more than 1 business owner, all application sections prior to this section only need to be completed by one business owner. Subsequent owners only need to fill in the “Legal Name of the Business” field. All financial information can be filled in with estimates. However, if you are pre-qualified for financing, we will ask for a complete and accurate financial statement and personal balance sheet from each applicant and or guarantor.

Last Name*

First Name*

Date of Birth *
00/00/0000

Social Security Number*
###-##-####

% Ownership

Home Address*

City* State* Zip* Title

Home Phone

000-000-0000

Cell Phone

000-000-0000

Email Address

Are you or your spouse a veteran of the armed forces?  Yes No

Are you a U.S. citizen, or legal resident? Yes No

Have you been convicted of a felony? Yes No

5. Personal Assets

Total Monthly Household Income

Total Monthly Household Expenses

Cash on Hand:

Credit Card Balance:

Bank Accounts:

Bank/Student Loan Balance:

Real Estate Value(s):

Real Estate Balance(s):

Automobile Value(s):

Automobile Balance(s):

Investments & Other Assets:

Other Liabilities:

6. Authorization and Certification

I authorize MetroAction to make inquiries as necessary to verify the accuracy of the statements made and to determine my credit worthiness through a personal credit check. I hereby certify that all information contained in this document and any attachments is true and correct to the best of my knowledge.

Signature*                                 Date*