Clear Form
FIRST Intercontinental BANK Credit Application
Business Information
Legal Name of Business
Business Street Address (No P.O. Box)
Business Phone
City
State
Zip
Type of Business:
Business Taxpayer ID
Date Business Started
Business Owned Since
Annual Revenues/Sales
Number of Employees
Year
□ Sole Proprietor
□ Partnership
Number of Locations
Net Profit or Loss
Business Checking Balance
Present Banking Relationship
Ownership (check one)
Business Fax
□ C Corp
Year
Business Savings Balance
□ S Corp
□ LLC
Business Loans Balance
□ Other ____________________
Loan Request Information
Amount of Credit Requested:
Purpose of loan:
Use of Proceeds:
$_______________________
$_______________________
$_______________________
$_______________________
$_______________________
$_______________________
$_______________________
$_______________________
Collateral Available:
Accounts Receivable
Inventory
Equipment Purchase (attach invoice)
Real Estate Purchase
Real Estate Improvements
Debt Refinancing (attach list to refinance)
Vehicle Purchase (attach invoice)
Other (please describe) ________________________________________________________________________
Please describe and supply market value. Include any assets to be acquired with proceeds of this loan:
Accounts Receivable
Value
Equipment Purchase
Value
Real Estate Purchase
Value
Vehicle Purchase
Value
Other
Value
Is any collateral offered to First Intercontinental Bank currently pledged to other creditors?.........................................
If yes, please explain. (Attach additional sheet if necessary)
□ Yes
□ No
Instructions and Financial Documentation Required:
1. Complete and sign the application.
2. The following financial information is required:
• Most recent three years of tax returns on the business (if the last year’s tax return is on extension, provide a copy of the extension for the most recent
year and a year-end business financial statement for the year on extension);
• CPA reviewed or audited financial statements, if available;
• Interim business financial statement less than sixty days old;
• Personal financial statement on each 20 percent or greater business owner (form available);
• Most recent three years of tax returns on each 20 percent or greater owner (if the last year’s tax return is on extension, provide a copy of the extension
for the most recent year and W-2s for the year on extension);
• Management resume
• Copy of signed Purchase Agreement if loan proceeds are to be used for purchase or real estate or a business;
• Legal description of real estate if loan proceeds are to be used for purchase or refinance of real estate;
• Business Plan if business is less than two years old, or if business cash flow is not sufficient to service debt requested.
.
Owner Information
List all officers, directors, partners, owners & co-owners, and stockholders with 20% or more of all stock issued. Must show 100% ownership. Use additional sheets if necessary.
Owner #1 Name
% Ownership
Social Security Number
0.00%
Title/Position
Home Telephone
Present Address
Business Telephone
City
From
State
To
Previous Address
City
From
State
Zip
To
Race
Sex
Date of Birth
Place of Birth
U.S, Citizen
□ Yes
Female
Military Service
□ Yes
Zip
From
□ No
To
□ No
Owner #2 Name
% Ownership
Social Security Number
0.00%
Title/Position
Home Telephone
Present Address
Business Telephone
City
From
State
To
Previous Address
City
From
State
Zip
To
Race
Sex
Date of Birth
Place of Birth
U.S, Citizen
□ Yes
Male
Military Service
□ Yes
Zip
From
□ No
To
□ No
Certification, Authorization and Signatures
The undersigned hereby certify that the enclosed information (plus any attachments or exhibits) is valid, correct and complete to the
best of my/our knowledge.
The undersigned hereby authorize the release to First Intercontinental Bank of any and all information it may require at any time for any
purpose related to this credit application, including inquiries to the Internal Revenue Service and any local credit bureau reporting
agencies.
The undersigned further authorize First Intercontinental Bank to release such information to any entity it deems necessary for any
purpose related to this credit application.
The undersigned further agree to notify the Bank promptly of any material change in any information related to this application.
The undersigned hereby acknowledge that all loan approvals will be in writing and subject to the terms and conditions set forth in a
commitment letter signed by an officer of First Intercontinental Bank.
IMPORTANT APPLICANT INFORMATION – Federal law requires all financial institutions to obtain and record information to verify your
identity. What this means for you: You may be asked several questions and asked to provide one or more forms of identification to fulfill
this requirement. In some instances we may use outside sources to confirm the information. The information you provide is protected by
our privacy policy and federal law.
Owner #1 Signature
Title
Date
Owner #2 Signature
Title
Date
FIRST Intercontinental BANK
PERSONAL FINANCIAL STATEMENT
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, or (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
(Omit Cents)
Cash on hand & in Bank……………………
(Describe in Section 2)
$
Savings Accounts…………………………...
$
IRA or Other Retirement Account…………
$
Accounts & Notes Receivable……………..
$
Life Insurance-Cash Surrender Value Only.
(Complete Section 9)
LIABILITIES
(Omit Cents)
Accounts Payable…………………………..
$
Notes Payable to Banks and Others……...
$
(Describe in Sections 3)
Installment Account (Auto)…………………
Mo. Payments....... $_______________
$
$
Installment Account (Other)………………..
Mo. Payments....... $_______________
$
Stocks and Bonds……………………………
(Describe in Section 4)
$
Loan on Life Insurance……………………..
$
Mortgages on Real Estate…………………
$
Real Estate……………………………………
(Describe in Section 5)
$
Automobile-Present Value…………………..
$
Other Personal Property…………………….
(Describe in Section 6)
$
Other Assets………………………………….
(Describe in Section 6)
$
Total
(Describe in Section 5)
Unpaid Taxes………………………………..
$
Other Liabilities……………………………..
$
(Describe in Section 8)
Total Liabilities………………………………
$ 0
Net Worth…………………………………….
$
Total
$
$ 0
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 Special Debt………………………….
$
Other Income (Describe in Section 7)……... $
Section 2. Description of Deposit Accounts (Describe in detail)
Financial Institution
Name and Address
Account Type
(Checking, Savings, etc)
Account Number
Account Balance
Section 3. Notes Payable to Bank and Others
(Use attachments if necessary. Each attachment must be identified as a part of this statement and signed)
Original
Current
Payment
Frequency
Name and Address of Note Holder(s)
Balance
Balance
Amount
(monthly, etc)
How Secured or Endorsed
Type of Collateral
Section 4. Stocks and Bonds
(Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.)
Number Of Shares
Quotation/Exchange
Name of Securities
Cost
Market Value
Date
Total Value
Section 5. 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
Type of Property
Address
Date of Purchase
Original Cost
Present Market Value
Name and Address of
Mortgage Holder
Mortgage Account No.
Mortgage Balance
Amount of Payment per
Monthly/Year
Status of Mortgage
Section 6. Other Personal Property and Other Assets
Section 7. Other Income
(Describe. If any is pledged as security, state name & address of lien holder, amount
of lien, terms of payment. If delinquent, describe delinquency.)
*Alimony or Child Support payments need not be disclosed in “Other Income” unless it is desired to have payments
counted toward total income
Section 8. Other Liabilities (Describe in detail)
Section 9. Life Insurance Held
Name of
Insurance Company
Owner of Policy
Beneficiary
Face Amount
Cash Surrender
Value
Policy
Loans
I authorize Lender (First Intercontinental Bank) to make inquires 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:
FIRST Intercontinental BANK
HISTORY OF THE BUSINESS
(Use separate attachments to answer questions, if necessary)
Nature of the Business:
Types of Products /Services:
Customer Profile:
List Key Customers:
List Major Competitors:
Major Past Accomplishments:
Future Plans for Growth/Expansion:
How will this loan benefit your company?
Will the funding of this loan create new employment opportunities?
If so, state how
□ Yes
□ No
FIRST Intercontinental BANK
MANAGEMENT RESUME
Please fill in all spaces, use full first, middle and maiden names—no initials. If an item is not applicable, please indicate so. You may
include additional relevant information on a separate exhibit. Sign and date where indicated.
Name
SS#
First
Middle
Maiden
Last
Date of Birth
Place of Birth
Home Telephone
Business Telephone
Residence Address
Street
City
State
Zip
Street
City
State
Zip
Previous Address
Lived there from
To
Month and Year
Month and Year
Spouse’s Name
SS#
First
Middle
Maiden
Last
Are you employed by the U.S. Government?
Are you a U.S. Citizen?
Agency/Position
□ Yes □
No
If no, give Alien Registration Number
Have you ever been charged with or convicted of any criminal offense other than a misdemeanor involving a motor vehicle violation?
Are you current on all taxes?
□ Yes □
No
□ Yes □
□ Yes □
Do you have any liens/judgments
No
If yes furnish details in a separate exhibit.
No
EDUCATION
College or Technical Training Name & Location
Dates Attended From/To
Major
MILITARY SERVICE BACKGROUND
Branch
From
Rank at Discharge
To
Honorable Discharge
Major assignment/accomplishment
WORK EXPERIENCE (List chronologically, beginning with present employment)
Company Name/Location
From
To
Title
To
Title
To
Title
Duties
Company Name/Location
From
Duties
Company Name/Location
From
Duties
Signature:
Date:
Degree or Certificate
FIRST Intercontinental BANK
PERSONAL BUDGET
INCOME
MONTHLY
Gross Salary or Draw (per latest Tax Return or Pay Stub)
Spousal Salary (Per latest Tax Return or Pay Stub)
Gross Rental Income
Interest / Dividend Income
Other Income
TOTAL INCOME
$ 0.00
EXPENSES
Residence Mortgage or Rent
Rental Property Mortgage
Rental Property Expenses
Auto Loan Payments (List all debts on Financial Statement)
Installment Payments (List all debts on Financial Statement)
Credit Card Payments (List all debts on Financial Statement)
Utilities & Phone
Insurance Payments
Food, Clothing
Income Tax
Property Tax
Alimony
Child Care/Support
Other
Miscellaneous (10% of Monthly Income)
TOTAL EXPENSES
$ 0.00
NET EXCESS INCOME
$ 0.00
I /we hereby certify that the above information is true and correct to the best of my/our knowledge and belief.
Signature:
Date:
Signature:
Date: