Firm Name: (if N/A use your name)
 DBA:        
E-Mail,       
Phone (With Area Code)  
FAX (With Area Code)   

Address
City: ST Zip:

Type of Business

Sole Owner    LTD Partnership      Gen. Partnership
Corporation       Date Est. Date Inc.
Will Inc Before Funding

Franchise Location Address
Enter Complete FanchiseLocation Address, with Zip

Principals or Officers

1. Name/Title Social Sec No.
Home Ph.      

          Home Address

2. Name/Title Social Sec No.
Home Ph.     

      Home Address

Bank Reference

1. Bank Name     Account No.
Type Of Account Checking Loan Savings 401K, IRA Other        Bank Officer
Bank or Contact Phone:

2. Bank Name     Account No.
Type Of Account Checking Loan Savings 401K, IRA Other        Bank Officer
Bank or Contact Phone:

3. Bank Name     Account No.
Type Of Account Checking Loan Savings 401K, IRA Other        Bank Officer
Bank or Contact Phone:

Term Reference Term Debt or Credit Reference
(Personal Or Business)

1. Business Name Acct. No.
Contact Phone

2. Business Name Acct. No.
Contact Phone

3. Business Name Acct. No.
Contact Phone

Franchise

Name Amount To Be Financed.
Equipment Leaseholds Signage

Type Of Equipment
Describe if Possible

Part II: Personal Statement

Assets (Enter Amount in Each Box)
Cash Checking Savings
CD's Life Insurance Cash Value
Marketable Securities: Stocks Bonds

Total Value of IRA's 401k

Is 401k accessible? YES NO

Non-Marketable Securities: Total:

Real Estate Owned: Total:

Accounts Receivables: Total:

Personal Property: Total:

Other Assets: Total:
                      Itemize
         Enter Specific Items of Value

Liabilities

Notes Payable To Banks -Secured   
Notes Payable To Banks -Unsecured
Notes Payable To Others                  
Accounts Payable                             
Unpaid Income Tax                          
Real-Estate Mortgages Payable        
Loans On Insurance                         
Loans On 401k                                
Credit Card Debt                             
Other Debts -Itemize                        
Itemize

Using The Figures Provided above Show:

Total Liabilities                        
Net Worth                             
Total Liabilities and Net Worth

Annual Sources Of Income.

Salary, bonus, commissions
Dividends                             
Real Estate Income             
Other Income:                     

Personal and General Information

Do you have a will?         Yes No
If yes, name of executor:

Are you a partner or officer in any other venture:
Yes No        Optional Info

Are you obligated to pay alimony, child support, or maintenance payments.
SSN     Yes No

        If Yes Describe

Are any assets pledged? Yes No
Are you a defendant in any suits or legal actions?
            Yes No

Personal Bank Accounts Carried at:
:

Have you ever taken Bankruptcy?
Yes No Explain

Do You Have Any Contingent Liabilities
Other Special Debt:
Amount of Contested Income Tax Liens

Who Referred you to Franchise-Finance?

Name:          

Company:     

Address:      

Phone:         

Submitted By

Enter Message, (Optional):

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