Amerifund Application Form

CONTACT INFORMATION

Complete Legal Name:

Billing Address:

City:

County:

State:

Zip Code:

Daytime Phone:

E-mail:

Contact:

LOAN/LEASE REQUEST

Total $ Amount:

Equipment Description:

Vendor/Supplier:

Address:

City:

State:

Zip:

Daytime Phone:

E-mail:

Contact:

TYPE OF BUSINESS

Non Profit, Sole Proprietorship, Partnership, Corporation:

# of years in business under current owner:

LOCATION OF PROPERTY (if other than Billing Address of Lessee)

Street Address:

City:

County:

State:

Zip:

PERSONAL INFORMATION ON OFFICERS, PARTNERS OR GUARANTORS

Name:

Title:

Social Security #:

Home Phone:

Home Address:

City:

County:

State:

Zip:

Are you a US Citizen (if no, explain status)?

Name:

Title:

Social Security #:

Home Phone:

Home Address:

City:

County:

State:

Zip:

Are you a US Citizen (if no, explain status)?

BUSINESS/PERSONAL BANK REFERENCES - TWO YEAR HISTORY (important to establish any loan history - attach copies of bank statements)

Name of Bank/Branch:

How Long:

Telephone Number:

Contact:

Checking Account #:

Savings Account #:

Loan Account #:

Name of Bank/Branch:

How Long:

Telephone Number:

Contact:

Checking Account #:

Savings Account #:

Loan Account #:

TRADE REFERENCES - TWO YEAR HISTORY (important to establish high credit and payment history)

Name of Supplier:

City:

State:

Telephone Number:

Contact:

Name of Supplier:

City:

State:

Telephone Number:

Contact:

Name of Supplier:

City:

State:

Telephone Number:

Contact:

Name of Supplier:

City:

State:

Telephone Number:

Contact:

BUSINESS LANDLORD/MORTGAGEE - TWO YEAR HISTORY (important to establish high credit and payment history)

Company Name:

Contact:

Telephone Number:

Insurance Company:

Contact:

Telephone Number:

Referred by:

Amerifund Account Manager:

Cover Letter
(Explanation of reason for funding)

Personal Financial Statement

Principal #1
Name:
City, State, Zip:
Date of Birth:
Business Name:
City, State, Zip:
Length of employment:
Address:
Social Security #:
Position or Occupation:
Bus. Address:
Length at present employment:
Principal #2 (if applicable)
Name:
City, State, Zip:
Date of Birth:
Business Name:
City, State, Zip:
Length of employment:
Address:
Social Security #:
Position or Occupation:
Bus. Address:
Length at present employment:

Have (either of) you or any firm in which you were a major owner ever declared bankruptcy, or settled for debts for less that the amounts owed? If yes, please provide details by clicking here.	No	Yes	When
Are (either of) you a defendant in any suit or legal action?	No	Yes	When
Are (either of) you presently subject to any unsatisfactory judgments or tax liens?	No	Yes	When
When, if ever, have (either of) you been audited by IRS?	No	Yes	When

ASSETS	IN EVEN DOLLARS
Cash on Hand
Non-Marketable Securities - See Schedule B
Restricted or Control Stocks
Partnership Interest - See Schedule C
Loans Receivable
Marketable Securities - See Schedule A
Securities held by Broker in Margin Accounts
Partial Interest in Real Estate Equities
Real Estate Owned - See Schedule D
Automobiles and Other Personal Property
Other Assets - Itemize



Total Assets

LIABILITIES	IN EVEN DOLLARS
Notes Payable to Banks
Amounts Payable to Others
Accounts and Bills Due
Other Unpaid Taxes and Interest
Due to Brokers
Loans on Life Insurance - See Schedule E
Unpaid Income Tax
Real Estate Mortgages Payable See Schedule D
Other Debts - Itemize



Total Liabilities
Net Worth
Total Liabilities & Net Worth

ANNUAL SOURCE OF INCOME
Salary, Bonus & Commissions
Real Estate Income
TOTAL
Net Income
Dividends
Less Living Expenses
CONTINGENT LIABILITIES
Do you have any Contingent Liabilities
On Leases or Contracts
Other Special Debt
As Endorser, Co-Maker, or Guarantor
Legal Claims
Amount of Contested Income Tax Liens

If your application for business credit is denied, you have the right to a written statement of the specific reason(s) for denial. To obtain the statement, please contact Amerifund, 9019 E. Bahia Dr., # 100 , Scottsdale, AZ, 85260, (480) 607-1122 within 60 days from the date of our decision. We will send you a written statement of the reason(s) for the denial within 30 days of receiving your request for the statement.

NOTICE: The federal Equal Credit Opportunity Act prohibits creditors from discriminating against applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract), because all or part of the applicant's income derives from any public assistance program, or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act, the federal agency that administers compliance with this law concerning this credit is the Federal Deposit Insurance Corporation, 25 Ecker Street, Suite 2300, San Francisco, CA.

I certify that the above given information given for the purpose of obtaining credit is true and correct. I authorize the person or firm to whom this application is made, any credit bureau or investigative agency employed by such person to investigate the references herein listed or other persons pertaining to my credit. I understand the terms of this instrument are not binding on Amerifund until accepted in writing by them.

_______________________________________________________
Signature, Title, Date

Don't forget to include:
Last 2 years personal tax returns (complete copies)
Last 2 years business tax returns (complete copies)
Current business financial statement and/or projection on new business
Last 3 years end business financial statement and tax returns unless in business only 2 years, then submit thins information for 2 years.
Resume on all key principals

Fax the completed form to: 800-211-3072, or

Mail the completed form to:
Amerifund, Inc.
9019 E. Bahia Dr., # 100

Scottsdale, AZ 85260

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