5- Applicant Questionnaire - Arizona Capital Source

This field is for validation purposes and should be left unchanged.

Company Name

Name

First Last

Do you and/or your spouse hold a trust?

Owner Yes

Spouse Yes

Both Yes

Both No

What is the name of the trust?

Do you or any member of your household work for the, U.S. Government, SBA, SCORE, or any other Federal Agency?

Owner Yes

Spouse Yes

Both Yes

Both No

Do you or your spouse have income outside of the business being financed?

Owner Yes

Spouse Yes

Both Yes

Both No

From where and what is the annual salary?

Are you a U.S. Citizen?

Owner Yes

Spouse Yes

Both Yes

Both No

Please provide Alien Registration Number

Are you presently under indictment, on parole or probation?

Owner Yes

Spouse Yes

Both Yes

Both No

Have you ever been arrested in the past 6 months for any criminal offense

Owner Yes

Spouse Yes

Both Yes

Both No

Do you have any past misdeamonors or felonies?

Owner Yes

Spouse Yes

Both Yes

Both No

Are you or the business involved in any lawsuit at this time?

Owner Yes

Spouse Yes

Both Yes

Both No

Have you or the business been involved in any past or current bankruptcies?

Owner Yes

Spouse Yes

Both Yes

Both No

Do you or the business have any unpaid taxes, including income, sales, or property?

Owner Yes

Spouse Yes

Both Yes

Both No

Has the business, or any of its owners, ever had any previous government financing, including SBA loan, even if paid off?

Owner Yes

Spouse Yes

Both Yes

Both No

Information for Government Monitoring Purposes

The following information is requested by the Federal Government for Certain types of loans. You are not required to furnish this information, but are encouraged to do so. The law provides 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, this Lender will note race and sex on the basis of visual observation or surname. If you do not wish to furnish the information below, please check the appropriate box.

Owner: With what race do you most closely identify? (Choose only one)

White

African American

Eskimo or Aleut

Puerto Rican

Hispanic

Asian/Pacific Islander

Native American

I do not wish to disclose

Owner: Gender

Male

Female

I do not wish to disclose

Spouse: With what race do you most closely identify? (Choose only one)

White

African American

Eskimo or Aleut

Puerto Rican

Hispanic

Asian/Pacific Islander

Native American

I do not wish to disclose

Spouse: Gender

Male

Female

I do not wish to disclose

Release of Information Consent

THE UNDERSIGNED hereby authorizes Arizona Capital Source (“ACS") to make inquiries as necessary to verify the accuracy of the information made and to determine creditworthiness. Further it authorizes ACS to submit Applicant’s loan package, including financial information, to one or more lenders for their consideration to provide the Third Party Loan in connection with Applicant’s U.S. Small Business Administration 504 Loan. Applicant understands that a lender’s decision to provide the Third Party Loan to Applicant is made by that lender in its sole discretion, and that ACS is not authorized to act on behalf of such lender or to make any representations to Applicant which would be binding upon such lender. Applicant also understands that ACS’s role in assisting Applicant to secure a Third Party Loan is only to prepare and submit Applicant’s loan package to potential lenders. While Applicant authorizes ACS to submit Applicant’s loan package, Applicant does not authorize ACS to make any representations to potential lenders which would be binding upon Applicant. Applicant further agrees to cooperate in providing any lender to whom Applicant’s loan package is submitted by ACS with such additional information or documentation as that lender may request in order evaluate and underwrite the Third Party Loan. Applicant understands that ACS may receive a referral fee from the lender who agrees to provide the Third Party Loan to Applicant payable at the time that the Third Party Loan funds and that neither ACS nor that lender will charge the referral fee to Applicant.

Owner Signature

Spouse Signature

Date

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IP Address

Applicant Questionnaire

Information for Government Monitoring Purposes

Release of Information Consent

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