1. Describe your business (products and/or services).

2. Legal Structure?

Corporation
Partnership
Sole Proprietorship
LLC
Other, please explain

3. How long has the company been in this business?

4. Number of Employees?
Weekly Payroll amount?

4a. Federal Tax ID Number:

5. How many customers do you have?

6. How many of the customer accounts listed above do you desire to on factor on a monthly basis.

7. Indicate the total dollar volume of Accounts Receivables available on a monthly basis ($):

8. What is your average monthly sales or billing volume? ($)

9. What percentage of your accounts are:

10. Are your Accounts Receivables hypothecated or used as collateral for any other loan?
Yes
No

11. Does the company have any past due Federal or State taxes?
Yes
No

a. If yes, indicate the amount ($):


b. Has a tax lien been filed:
Yes
No

12. Are there any judgments or pending lawsuits filed against the company or any of the company's principals?
Yes
No

a. If yes, please explain:

13. Has the company factored in the past?
Yes
No

a. If yes, indicate the name of the company:


14. Does the company have any outstanding loans?
Yes
No

a. If yes, indicate the amount and the name of the bank or financial institution:


15. How is the company currently being financed?

Bank
Internal Operations/Cashflow
Investors
Other, please explain

16. List your top five (5) customers (contact person, title, company name, address, city and state, zip code).  Your customers will not be contacted.  This information is needed to confirm the credit quality of your customers.

17. Do you have any special situations or other information that would be helpful in evaluating your company for our financing programs?