MIDA - Application

Middle Monongahela Industrial Development Association, Inc.

Mon Valley Loan Fund Application

Legal Name of Applicant: ______________________________________________________________

Tax ID or Social Security # _____________________________________________________________

Address: ____________________________________________________________________________

___________________________________________________________________________________

Phone #__________________ Fax # _________________ Date Business Established: _______________

Type: ______Proprietorship ________Partnership ______Corporation

PRINCIPALS:

Name    ____________________________                       Name _______________________________
Address ____________________________                    Address _______________________________
               ____________________________                                   _______________________________
Phone    ____________________________                   Phone _______________________________

Name    ____________________________                     Name    _______________________________
Address ____________________________                    Address _______________________________
            ____________________________                                   _______________________________
Phone    ____________________________                   Phone _______________________________

DESCRIPTION OF BUSINESS ACTIVITY:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

LOAN REQUEST:
Purpose: __________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Total Project Cost: ____________________ Loan Request:________________________

JOBS TO BE CREATED:                                 Number                             Year
                                                                         ______                             ____
                                                                         ______                             ____
                                                                         ______                             ____

COLLATERAL OFFERED:

Real Estate:      BO/TP              Desc.                     Deed Bk/Pg No.           FMV                Liens
                         _____               ________            ____________            _____              _____
                         _____               ________            ____________            _____              _____
                         _____               ________            ____________            _____              _____

Equipment:    Name/Desc                 SerialAD #                Quantity             FMV          Liens
                     _____________      _____________        ________       ________      _______
                    _____________      _____________        ________       ________      _______
                   _____________      _____________        ________       ________      _______

Inventory:         Narne/Desc.                  Quantity               FMV                  Liens
                        _____________      _____________       ________       ________
                        _____________      _____________       ________       ________
                        _____________      _____________       ________       ________

Other: ____________________________________________________

SUPPLEMENTAL INFORMATION REQUIRED:

                            _______ Pro Forma Financials for 3 years.
                            _______ Income/Expense Statements for____years
                            _______ Balance Sheet for ____years.
                            _______ Income Tax Returns for years.
                            _______ Interim Finance Statement to Date.
                            _______ Personal Financial Statement(s).
                            _______ Property Appraisal(s).
                            _______ D & B Report.
                            _______ UCC Secured Transactions Search.
                            _______ Corporate Resolution/Partnership Agreement/Proprietorship Affidavit.

BUSINESS FINANCIAL DATA

Does the business have a line of credit secured by account receivables or inventory?

_______Yes _______ No Credit Limit $__________ Balance $ ____________

	Accounts Receivable	Inventory	Machinery & Equipment	Land & Building	Other Assets	Trade Payables List Balance Below	List other Outstanding Debt
Present Value
Present Loan Balance
Monthly Payment

Are any Federal income tax or State income tax liabilities past due for the Applicant or for any owner/partner of an Applicant which is a Sub Chapter "S" corporation/partnership, or for any possible guarantors (s)? ________ No __________Yes

If yes, what aggregate amounts are delinquent:                  Federal $ __________________
                                                                                      State      $ __________________
                                                                         Past Due Since:     __________________

Is your business a party to any claim or lawsuit ? ________No _________Yes
(Attach Details)

Have you ever owned or operated a business which declared bankruptcy? _____No _____Yes
(Attach Details)

MANAGEMENT/OWNERSHIP

List possible guarantors, owners and partners (100% of ownership must be shown)

Name                    Title                  %Ownership             Home Address                                        Social Security No.
___________   _________     ______________   _____________________________ ________________
___________   _________     ______________   _____________________________ ________________
___________   _________     ______________   _____________________________ ________________
___________   _________     ______________   _____________________________ ________________

RELATIONSHIP INFORMATION

Primary Business Banking Institution Average Monthly Deposit Balance Account # Date Established
___________________________ $____________________ _________ ___________

Primary Personal Banking Institution Average Monthly Deposit Balance Account # Date Established
___________________________ $____________________ _________ ___________

BANKING REFERENCES:________________________________________________

___________________________________________________

I/We authorize the lender to make whatever credit inquiry it deems necessary in connection with this credit application or in the course of review or collection of any credit extended in reliance on the application. I/We authorize and instruct any person or consumer reporting agency to compile and furnish to the Lender any information it may have or obtain in response to such credit inquiries and agree that the same shall remain your property whether or not credit is extended.

All information set forth in this application is declared to be a true representation of the facts for the purpose of obtaining the credit requested any willful misrepresentation on this application could result in criminal action.

__________________________________
(Business Name)

ATTEST:

____________________________________ by: ______________________________ Secretary/Treasurer President/Vice President

WITNESS.

____________________________________ _______________________________
Proprietor/Partner

DECISION: Approval Denial

Loan Committee: ________ ________

Executive Committee: ________ ________

TERMS: Amount: ______________ Term:____________ Rate: ______________

Documents to be prepared: ________ Promissory Note

________ UCC Security Agreement

_______ Equipment

_______ Inventory

________ Mortgage

________ Personal Guaranty

Closing Date: ________________________