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2. 
3. Tipp City Revolving Loan Fund Application
   
   

   
   

5. Applicant Information
7. First Name
8. Last Name
10. Address
12. City
13. State
14. Zip Code
16. Phone Number
17. TIN
19. Email Address
21. Source of Income
23. Corporate References - With Phone Numbers. Please List Two.
25. Reference #1
26. Phone Number
28. Reference #2
29. Phone Number
31. Business Overview
33. Business Name
35. Business Address
37. City
38. State
39. Zip Code
41. Business Phone
42. Percent Owned by a US Citizen or Legal Resident
44. Description of Business
46. Business Status (Check One)

    1. Start-Up/New (12 Months or less)
    2. Existing Business (Greater than 12 Months
48. Business Structure (Select One)

    1. Sole Proprietorship
    2. Partnership
    3. Limited Liability Co.
    4. Corporation S
    5. Corporation C
50. Type of Business (Select One)

    1. Service
    2. Retail
    3. Wholesale
    4. Agricultural
    5. Manufacturing
    6. Green Product/Service
    7. Other
52. Annual Gross Sales
53. Number of Employees (full-time equivalent)
55. Where Do You Bank for Your Business?
57. Have you ever owned or been involved in a small business before? Explain
59. Loan Request & Collateral
61. Loan Uses
62. Collateral (Market value)
64. Real Estate Purchase
65. Appraisal
67. Purchase Equipment
68. New Equipment
70. Repair Equipment
71. New Inventory
73. Leasehold Improvements
74. New Furniture/Fixtures
76. Furniture/Fixtures
77. New Supplies
79. Purchase of Inventory
80. Existing Equipment
82. Purchase of Supplies
83. Existing Inventory
85. Insurance Premiums
86. Existing Furniture
88. Fees/Licenses
89. Existing Supplies
91. Working Capital - Rent
92. Land
94. Working Capital - Advertising
95. Building
97. Working Capital - Deposits/Fees
98. Vehicle (No Liens)
100. Working Capital - Salaries
101. Other
103. Total Working Capital
104. TOTAL Collateral
106. Other
108. TOTAL Loan Request
110. Required RLF Application Attachments
112. Business Plan
113. Cash Flow
115. Proof of Workers Compensation
116. Current Balance Sheet (Personal & Business)
118. Profit & Loss Statements (2 Years)
119. Tax Returns (1 Year - Personal & Business}
121. DUNS Number
122. NAICS Code
124. Application Agreement
126. (a) All information in this application and the attached exhibits are true and complete to the best of my/our knowledge and is submitted to the Revolving Loan Fund Committee for its recommendation to the City of Tipp City Community Improvement Corporation in order for the TC CIC to decide whether to grant a loan or to participate with a lending institution in a loan for my/our proposed project.
128. (b) I/We authorize disclosure of all information submitted in connection with this application to the Revolving Loan Fund Committee and the Tipp City Community Improvement Corporation. I/We understand that all information may be subjected to public review under public disclosure laws.
130. (c) As consideration for any management and technical assistance which may be provided, I/we waive all claims against the Revolving Loan Fund Program and the Tipp City Community Improvement Corporation.
132. (d) I/we agree to pay for any appraisal/legal costs and/or filing fees to complete my/our application.
134. (e) I/we agree that the Revolving Loan Fund Program or the Tipp City Community Improvement Corporation may compile information through the credit bureau about my/our creditworthiness. I/we hereby submit a non-refundable application fee in the amount of $150 with this application.
136. Electronic Signature Agreement

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
138. Electronic Signature
140. This institution is an equal opportunity provider and employer. The following information is requested by the Federal Government for certain types of loans, in order to monitor the lender's compliance with equal credit opportunity. You are not required to furnish this information, but are encouraged to do so. The law requires that a lender may neither discriminate on the basis of this information nor on whether you choose to furnish it. However, if you choose not to furnish it, under Federal regulations, this lender is required to note race/ethnicity on the basis of visual observation or surname. If you do not wish to famish the above information, please check below.
142. Ethnicity
     -- Select One --Hispanic or LatinoNot Hispanic or Latino
143. Gender
     -- Select One --FemaleMale
145. Race
     -- Select One --American Indian/Alaskan NativeAsianBlack or African AmericanNative Hawaiian or other Pacific Islander WhiteI choose not to finish this information
147. In accordance with Federal Law and US Department of Agriculture policy, this institution is prohibited from discrimination on the basis of race, color, national origin, sex, age or disability. (Not all prohibited bases apply to all programs.) To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD).
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149. 1. Receive an email copy of this form.
150. Email address

     This field is not part of the form submission.

151. Submit

* indicates a required field