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BLACK BUSINESS LOAN PROGRAM APPLICATION CHECKLIST

FAMU FCU requires the following documents for a complete review of your loan request.

1. Loan Application (Must be completed and signed by individual(s) who is African-American and owns 51% or more of the equity of the business, as evidenced by the businesses tax returns)

2. Copy of Driver’s License 3. Proof the business is located in a designated county in Florida and registered as a Florida

corporation 4. Complete Questionnaire 5. Complete the “Right to Financial Privacy Act” form 6. Business Tax Returns (at minimum, copies of the previous two years Federal Income tax returns

for the applicant business, including all schedules) or a written explanation if tax returns are unavailable.

7. Individual Tax Returns (at minimum, copies of the last six months’ pay stubs, previous two years Federal income tax returns, IRS Form 1040 and all schedules, for each individual business owner who completed and signed this application).

8. Complete Personal Financial Statement and proof of financials (Financials must be submitted for the individual with at least 51% of ownership of the business)

9. Proof of business insurance 10. A non-refundable Application fee of $200

NEW BUSINESS:

1. Provide a Business Plan (Plan must include 3 years of financial projections), preferably prepared by a Financial Advisor/CPA, but not required

ESTABLISHED BUSINESS:

1. Provide business and personal debt schedule 2. Provide current balance sheet and income statement 3. Provide Year-End Financial Statements for at minimum previous two years 4. Provide profit and loss financial statements for the current year-to-date

NOTE: Additional information may be requested by the Loan Committee to determine a loan decision. If requested, please provide additional information within 7 days of the request to prevent a delay in the approval/denial decision.

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APPLICATION Applicant’s Attestation I attest that the business has at least 51% black ownership and operational interests and is located in enter here name of county here County, Florida. I agree to obtain technical or managerial assistance if advised to do so. The undersigned, by signature on this document, verifies the information, attachments, supporting documents and material contained herein and are true and complete, that I/we have authority to apply for this loan on behalf of the business, and intend to repay the loan using funds available to myself/us or the business that will be used to repay the loan. The undersigned understands that Florida A&M University Federal Credit Union, and/or other financial institutions assisting the Corporation in its administration of this loan program for the State of Florida, may investigate the credit of the applicant or co- applicants for purposes limited to this application, and hereby authorized such investigation. The information in this application, and/or additional information obtained in connection with it processing, as authorized above, is confidential, and shall not be released to any party without the written permission of the applicant(s) expect for audit review by State or Federal agencies and upon request by financial institutions or agencies considering an extension of credit to the applicants). Misrepresentation of the above information could result in prosecution for fraud.

APPLICANT 1 APPLICANT 2 Print Name

Print Name

Signature

Signature

Date

Date

The applicant, by signature on this document, authorizes Florida A &M University Federal Credit Union (FAMU FCU) to verify the accuracy of the application and to procure such additional information, as FAMU FCU deems necessary to process the Black Business Loan Program (BBLP) request. The applicant further understands that FAMU FCU may investigate the credit record of the primary borrower(s) All information obtained shall remain confidential and will be used only for purposes directly connected with evaluating this application. This information shall not be released to any party outside of FAMU FCU without written permission of the applicant.

☐ Established Business ☐ Start-up mm/dd/yyyy Date Established mm/dd/yyyy Date Started Do you currently have an outstanding BBLP loan? ☐ Yes ☐ No

1. ORGANIZATION TYPE: ☐ Sole Proprietorship ☐ Partnership ☐ Corporation ☐ S-Corporation ☐ Limited Liability Company ☐ Other

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2. BUSINESS LEGAL NAME: (will be verified on sunbiz.org) Enter Business Name Here____________________________

BUSINESS OWNERS:

3. Is the Mailing Address the same as physical address? ☐ Yes ☐ No

If not, enter address here: Enter Address Here

4. Current Number of Employees: Enter # Here FULL TIME Enter # Here PART-TIME

5. Minority Business Enterprise (MBE) Certified: ☐ Yes ☐ No

6. BUSINESS FINANCIAL SUMMARY

BUSINESS HISTORY

1. Full Name FEIN

Borrower’s Signature

Title

Address Telephone#

City, State, Zip Email County Website

2. Full Name FEIN

Borrower’s Signature

Title

Address Telephone#

City, State, Zip Email

County Website

BUSINESS FINANCIAL SUMMARY 2015 2016 2017 Gross Revenues Total Employment /Payroll Expenses

Total Operating Expenses

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NATURE OF BUSINESS Click here to enter text.

TYPES OF PRODUCT/SERVICES Enter here

FUTURE PLANS FOR EXPANSION Enter here

PURPOSE OF LOAN Enter here

Loan Request Amount: $__________________________________ Least amount of funds needed, if loan amount requested is denied: $________________

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Please fill in all spaces, using full first, middle, maiden and last names – no initials. If an item is not applicable, please indicate. Name: ________________________________________________________________________ First Middle Maiden Last

Address: ____________________________________________________________________________________ Street City State Zip Previous: ____________________________________________________________________________________ Street City State Zip

Date of Birth: mm/dd/yyyy______________________

Place of Birth: Enter here_________________________

US Citizen: ☐ Yes ☐ No If No, Alien registration number Enter here

☐ Own ☐ Lease

Amount: $ ☐ Monthly ☐ Weekly ☐ Bi-weekly EDUCATION

College or Technical Training Name and Location

Date Attended Major Certificate

Degree

MILITARY SERVICE Are you claiming Veterans’ Preference? ☐ Yes ☐ No Please select the appropriate category that applies to you (if applicable): VETS 100A: ☐ Recently Separated Veteran ☐ Armed Forces Service Medal Veteran ☐ Other Protected Veteran ☐ Disabled Veteran Military Status: ☐ Current Member of National Guard ☐ Veteran/Retired Military ☐ Current Member of the Reserves ☐ Active Duty

Branch Dates From mm/yy To mm/yy

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Employment Experience Employer/Location _____________________________________________________________________________ From _________________________________ To ________________________ Title ________________________ Duties ________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Employer/Location _____________________________________________________________________________ From _________________________________ To ________________________ Title ________________________ Duties ________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Employer/Location _____________________________________________________________________________ From _________________________________ To ________________________ Title ________________________ Duties ________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Employer/Location _____________________________________________________________________________ From _________________________________ To ________________________ Title ________________________ Duties ________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

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RIGHT TO PRIVACY ACT BLACK BUSINESS LOAN PROGRAM

_____________________________________________________________________________________________ Applicant’s Signature Date _____________________________________________________________________________________________ Applicant’s Signature Date STATE OF FLORIDA COUNTY OF ______________________________________________________

Subscribed and Sworn before me this day of 20 .

Notary Public _

My Commission Expires:

This is a notice to you as required by the RIGHT TO FINANCIAL PRIVACY ACT of 1978 that the Florida A & M University Federal Credit Union has a right to access financial records held by any financial institution in connection with the consideration or administration of the BUSINESS LOAN for which you have applied. Financial records involving your transaction will be available to the Florida A& M University Federal Credit Union (FAMU FCU) without further notice or authorization but will not be disclosed or released to another Agency or Department without your consent, except as required or permitted by law. It is acknowledged that the FAMU FCU is a for profit organization; however, some funds utilized are from a public source. While the FAMU FCU believes in the privacy of its files, the confidentiality has not been tested under Florida Statute 119 – Public Records Law. A challenge for release would be protested vigorously; however, FAMU FCU reserves the right to defend or not. As a result, it is recognized that information provided may become public record. It is further understood that completing the loan application does not guarantee receiving a loan.

18 USCS 1001 Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact, or makes any false, of fictitious or fraudulent statements or representations, or makes or uses any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisonment not more than five years, or both. (June 25, 1948, Ch. 645 - 1.62 Stat 749.

I hereby certify that the foregoing information, submitted in support of my application for a business loan is true and complete to the best of my knowledge and belief. I further certify that the penalties under USCS Title 18, Section 1001, for false and fraudulent statement(s) (see above) has been explained to me. I acknowledge receipt of the Financial Privacy Act. I hereby waive all claims against the Florida A & M University Federal Credit Union and its personnel in connection with the assistance hereby requested.

NOTICE: THIS APPLICANT UNDERSTANDS THAT COMPLETION OF THIS APPLICATION DOES NOT GUARANTEE ASSISTANCE WITH THIS PROGRAM

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QUESTIONNAIRE

I acknowledge and attest to FAMU FCU, within the past five (5) years, I do not have a criminal record or convictions related to sexual abuse or violent crime for the purpose of determining my eligibility for a loan under the Black Business Loan Program.

_______________________________________________________________ Applicant 1 Signature Date

________________________________________________________________ Applicant 2 Signature Date

Answer all questions truthfully. Arrest or conviction records will not necessarily disqualify application; however, untruthful answers will result in application being denied. All answers that are yes, requires an explanation. Submit explanations on a separate sheet of paper.

1. For any criminal offense other than a minor vehicle violation, have you ever: 1) plead guilty; 2) been convicted; 3) plead nolo contendere; or 4) been placed on any form of parole or probation? ☐ Yes ☐ No 2. Have you been arrested in the last six months for any criminal offense?

☐ Yes ☐ No

3. Do you have any pending judgments against your business or you personally?

☐ Yes ☐ No

4. Have your business or you personally ever been involved in a bankruptcy? ☐ Yes ☐ No

5. Does your business or you personally have any past or pending lawsuits? ☐ Yes ☐ No

6. Does your business or you personally owe IRS back taxes?

☐ Yes ☐ No

7. Is there a lien against your business or you personally? ☐ Yes ☐ No

8. Does the business have a pending judgment? ☐ Yes ☐ No

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PERSONAL FINANCIAL STATEMENT

I authorize FAMU FCU to make inquiries as necessary to certify 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 obtaining a Black Business 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:

As of

Complete this form for: (1) each proprietor, or (2) each limited partner who owns 20% or more interest and each general partner, or (3) each stockholder owning 20% or more of voting stock, and (4) any person or entity providing a guaranty on the loan.

Name Business Phone Residence Address Residence

Phone

City, State, & Zip Code Business Name of Applicant/Borrower

Assets Liabilities Cash on hand & in Banks Accounts Payable Savings Accounts Notes Payable to Banks and Others

(Describe in Section 2)

IRA or Other Retirement Account Installment Account (Auto)

Accounts & Notes Receivable Monthly Payment $ Life Insurance – Cash Surrender Value Only

(Complete Section 8) Installment Account (Other)

Stocks and Bonds (Describe in Section 3)

Monthly Payment $

Real Estate (Describe in Section 4)

Loan on Life Insurance

Automobile-Present Vale Mortgages on Real Estate (Describe in Section 4)

Other Personal Property (Describe in Section 5)

Unpaid Taxes (Describe in Section 6)

Other Assets (Describe in Section 5)

Other Liabilities (Describe in Section 7)

TOTAL

TOTAL LIABILITIES

Net Worth

TOTAL

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

TOTAL TOTAL Description of Other Income in Section 1.

Section 3. Stocks & Bonds. (use attachments if necessary. Each attachment must be identified as a part of this statement & signed.)

Number of Shares

Name of Securities

Cost

Market Value Quotation/Exchange

Date of Quotation/Exchange

Total Value

Section 4. Real Estate Owned. (List each parcel separately. Use attachments, if necessary. Each attachment must be identified as a part of this statement and signed.)

Property A

Property B

Property C

Property D

Type if Property

Address

Date Purchased

Original Cost

Present Market Value

Name & Address of Mortgage Holder

Mortgage Account Number

Mortgage Balance

Amount of Payment per Month

Status of Mortgage Section 5. Other Personal Property & Other Assets (Describe and if any is pledged as security, state name & address of lienholder, amount of lien, terms of payment and if delinquent, describe delinquency.)

*Alimony or child support payments need not be disclosed in “Other Income” unless it is desired to have such payments counted toward total income.

Section 2. Notes Payable to Bank and Others (Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.)

Name & Address of Noteholder(s) Original Balance

Current Balance

Payment Amount

Frequency (Monthly-etc.)

How Secured or Endorsed Type of Collateral

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.

Insurance Company Face Amount Cash Surrender Amount Beneficiaries

FORECAST OF PROFIT / (LOSS)

_____________________________________________________________ Signature Date

ATTACH ASSUMPTIONS (Supporting documentation) TO THIS FORM

YEAR 1 % of Sales

YEAR 2 % of Sales

1. Total Sales (Net)

100%

100%

2. Cost of Sales

3. Gross Profit (Line 1 minus Line 2)

4. Expenses (operating)

5. Salaries (other than owner)

6. Payroll Taxes

7. Rent

8. Utilities (include phone)

9. Insurance

10. Professional Service (i.e. CPA, Attorney)

11. Taxes & Licenses

12. Advertising

13. Supplies (for business)

14. Office Supplies (forms, postage, etc.)

15. Interest (loans, contracts, etc.)

16. Depreciation

17. Travel (include operating costs of vehicle)

18. Entertainment

19. Dues & Subscriptions

20. Other Contingent

21. Total Expenses (add lines 5 thru 21)

22. Total Expenses (add lines 5 thru 21)

23. Profit Before Taxes (line 3 minus 22)

_________________________________________________________________________________ Signature Date

SCHEDULE OF DEBTS

Debt Obligation, as of ____________________________________, 2018

Existing Debt Obligations: List separately all obligations of the company evidenced by note. This section requires more detail than that found on

any CPA prepared financial statements. It is a critical part of the information we analyze.

CREDITOR NAME/ADDRESS

ORIGINAL DATE

ORIGINAL AMOUNT

PRESENT BALANCE

INTEREST RATE

MONTHLY PAYMENT

MATURITY DATE

COLLATERAL SECURITY

Total Present Balance: $ ___________________________________