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New Economy Project
NEW ECONOMY LOAN FUND INTAKE FORM
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1. APPLICANT INFORMATION
First Name
Last Name
Organization/Business Name
Organization/Business Address
City
State
Zip Code
Phone Number
Email
Preferred Method of Contact
Phone
Email
Mail
2. ORGANIZATION/BUSINESS DETAILS
Primary Contact
Phone Number
Type of Entity (e.g. Nonprofit, LLC)
Date Established
EIN/Tax ID Number
Number of Employees (Full-Time or Part-Time)
Briefly Describe your Organization/Business (including mission and services provided)
Briefly Describe your Governance Structure
Names and Titles of Owners/Key Management
Neighborhood(s) or Populations Served
3. LOAN REQUEST INFORMATION
Loan Amount Requested
$
Purpose of Loan/Use of Funds
- None -
Working Capital
Equipment Purchase
Expansion
Real Estate
Bridge Loan
Other (Please Specify)
Other Purpose
Preferred Loan Term: (e.g., 12 months, 3 years)
4. FINANCIAL INFORMATION FOR ORGANIZATION/BUSINESS
Annual Revenue - Please provide annual revenue for your most recent 3 years
Net Income - Please provide net income for your most recent 3 years
Current Assets
$
Current Liabilities
$
Debt Schedule: (List current debts and repayment terms)
5. PROJECT DETAILS (IF APPLICABLE)
Project Name
Project Description
Project Location
Project Start Date
Project Completion Date
Total Project Cost
$
Funds Raised/Committed
$
Sources of Funding
6. ADDITIONAL INFORMATION
Are you currently working with an accountant or finance consultant?
- Select -
Yes
No
Have you applied for loans or funding elsewhere?
Yes (please provide details)
No
Other Loans or Funding
Any additional information or comments
Submit
