FUNDING PROJECT DATA INFORMATION SHEET

  The following is a simple project data information request sheet.
Please fill out all information and indicate those, which are not applicable with (n/a.)
We will use the information in this project data sheet to evaluate your company’s
financial position so that we may offer a financial alternative tailored to your needs. 
It is therefore essential that all information indicated is accurate and complete.
If you have any questions, please do not hesitate to contact us at 800-866-3140.

Full Name of Project, Industry and Complete Address:


Your first and last name:

Company name or DBA:

Industry:


Your email address: (e.g.: you@aol.com)

Your mailing address:

When entering your mailing address,
please be sure to enter your
address, town, state and postal code in the field above.

Your telephone and fax number(s):

Additional phone, cell and fax numbers:

Time zone and best time to call:

Brief vision/mission statement:

Is the project government or private?

Loan amount requested.LTV sought:

Term of financing required:

How soon are funds needed, and is there a preferred time frame at which funds are to be obtained (1sr qtr, 2nd qtr, etc)?

Does the borrower have the reserves to pay for 3rd party reports? (appraisals, due diligence, etc.) Yes/No


If need be, will the borrower sign personally? Yes/No


At what stage is the project in locating the financing?


At this stage of the project, how soon are the negotiating parties able to enroll in the qualification process in order to obtain capital or loan funds?  Immediately/When requested


Amount of funds invested to date? Must be verifiable and available upon request US$:

Description of hard assets/collateral now present or currently available to be pledged toward the project:
 

Total value of all hard assets and/or collateral to be pledged is support of the financing requirement: US$


Does the project possess at this time a financial bond - bank guarantee (letter of credit, credit line, etc) bonds, insurance bond or any other security against which a loan can be issued?



Can the negotiating party meet a requirement for costs? (processing, due diligence, lender commitment fees or retainer, refundable at closing where or if applicable? Yes/No


Are the funds budgeted available, or will they be made available and verifiable to ensure the costs of application processing can be met? Yes/No


Our brokerage does charge  points or takes an equity stake inthe company, separate from all lender fees which is payable only at funding (success fee). Please advise us what is a negotiable percentage that we can agree upon.  %


How long has the company been seeking financing?


What types of financing have been obtained or worked with in the past?

What types of funding will be considered or preferred?

Is the company engaged with other funding sources at this time? Yes/No

Are you a loan broker? Yes/No. Brokers are welcome!

If yes, please identify these funding sources:

What stage has the application reached?

Is a loan offer available from this source?
 

What types of financing have been offered, if any?

Have you ever been declined? If so, why?


Describe any current credit issues (if any) surrounding the funding of your project:


Are you currently generating revenue from this or any other projects? Yes/No

If so, indicate the actual annual revenue for the past 3 years:

Year 1: (US Dollars)

Year 2: (US Dollars)

Year 3: (US Dollars)

What is the total amount of cash funds or existing credit funds that will be brought to the closing table by your group to complete this funding transaction? Please list amount in US funds.

Please indicate who introduced you to us (Hebda/Lapierre):


Please indicate which, if any, of the following are currenlty available: (check all that apply)
Executive Summary
Complete Business Plan
Pro Forma's or Contract Agreements
Management Profile
Organizational Chart
Financials
Resumes of the Management
Expected Breakdown of use of funds
Bank Guarantee or other collateral instrument
Letter of intent to supply the instrument from a rated institution
Letter of intent to fund or loan offer already issue by a lender

Other information relating to your funding request:
 

Please email your project's executive summary and other pertinent information to: backcountryjournal@hotmail.com.
When emailing, please be sure to type : "Executive Summary/Loan Information" in the subject line of your email message.


I declare the information that I have provided in this form is accurate, and the best of my knowledge and belief.
(No actual signature is required at this time)