Small Business Loan Request

	Property A	Property B	Property C
Type of Property
Name & Address of Title Holder
Date Purchased
Original Cost
Present Market Value
Name & Address of Mortgage Holder
Mortgage Account Number
Mortgage Balance
Amount of Payment per Month/Year
Status of Mortgage

Section 5. Personal Property and Other Assets.

(Describe, and if any is pledged as security, state name and address of lien holder, amount of lien, terms of payment, and if delinquent, describe delinquency.)

Section 6. Unpaid Taxes.

(Describe in detail, as to type, to whom payable, when due, amount, and to what property, if any, a tax lien attaches.)

Section 7. Other Liabilities.

(Describe in detail.)

Section 8. Life Insurance Held.

(Give face amount and cash surrender value of policies - name of insurance company and beneficiaries.)

I authorize SBA/Lender to make inquiries as necessary to verify the accuracy of the statements made and to determine my creditworthiness. I certify the above and the statements contained in the attachments are true and accurate as of the stated date(s). These statements are made for the purpose of either obtaining a loan or guaranteeing a loan. I understand FALSE statements may result in forfeiture of benefits and possible prosecution by the U.S. Attorney General (Reference 18 U.S.C. 1001).

Signature:

Date:

Social Security Number:

Signature:

Date:

Social Security Number:

Please Note:

The estimated average burden hours for the completion of this form is 1.5 hours per response. If you have questions or comments concerning this estimate or any other aspect of this information, please contact Chief Administrative Branch, U.S. Small Business Administration, Washington, D.C. 20416, and Clearance Office, Paper Reduction Project (3245-0188), Office of Management and Budget, Washington, D.C. 20503.

Name:	Business Phone:
Residence Address:	Residence Phone:
City, State and Zip Code:
Business Name of Applicant/Borrower:

ASSETS		LIABILITIES
Cash on hand & in banks	$ ______________	Accounts payable	$ ______________
Savings accounts	$ ______________	Notes Payable to Banks and Others	$ ______________
IRA or Other Retirement Account	$ ______________	(Describe in Section 2)
Accounts & Notes Receivable	$ ______________	Installment Account (Auto)	$ ______________
Life Insurance - Cash Surrender Value Only	$ ______________	Monthly Payment $_____
(Complete in Section 8)		Installment Account (other)	$ ______________
Stocks and Bonds	$ ______________	Monthly Payment $_____	$ ______________
(Describe in Section 3)		Loan on Life Insurance	$ ______________
Real Estate	$ ______________	Mortgages on Real Estate	$ ______________
(Describe in Section 4)		(Describe in Section 4)
Automobile - Present Value	$ ______________	Unpaid Taxes	$ ______________
Automobile - Present Value	$ ______________	(Describe in Section 6)
Other Personal Property	$ ______________	Other Liabilities	$ ______________
(Describe in Section 5)		(Describe in Section 7)
Other Assets	$ ______________	Total Liabilities	$ ______________
(Describe in Section 5)		Net Worth	$ ______________
Total Assets	$ ______________	Total Liabilities & Net Worth	$ ______________

Section 1. Source of Income
Source of Income		Contingent Liabilities
Salary	$	As Endorser or Co-Maker	$
Net Investment Income	$	Legal Claims and Judgments	$
Real Estate Income	$	Provision for Federal Income Tax	$
Other Income (Describe below)	$	Other Special Debt	$