Financing Request Questionnaire

Please complete all fields as accurately as possible. The information provided will be used by our team and potential capital partners to evaluate your financing request.

First Name

Last Name

Date Of Birth

Phone *

Email *

Primary Residence Address

Organization

Address

Street Address

City

State

Country

Postal Code

Date of Formation

Employer Identification Number (EIN)

Type of Entity (LLC / C-Corp / S-Corp / Partnership)

Registered Agent Name & Address

All members/shareholders and ownership percentages

Other entities in which you hold 20% or greater ownership interest

Have you ever filed for personal or business bankruptcy?

No
Yes, provide details

Are there any judgments, liens, or legal actions pending against you or your entities?

No
Yes, provide details

Have you ever been convicted of a felony or financial crime?

No
Yes, provide details

Transaction / Loan Details

Loan Amount Requested

Itemized use of proceeds

Requested Term:

Requested Interest Rate or Rate Type (fixed / variable / other)

Proposed Repayment Structure (interest only / amortizing / other)

Proposed Closing Timeline

Describe the committed capital: source, terms, and seniority (if available)

Collateral and Project Information

Property Address

Legal description of property

Current ownership status of land (owned / under contract / to be acquired)

Estimated land value and basis for valuation

Has a specific parcel of land been identified?

Yes

If yes, provide address, APN, and county

Equipment value

Patent numbers or intellectual property

Description of facility or infrastructure

Strategic Partnerships

Is there a signed supply agreement or LOI? If Yes, please share agreements or LOIs

Name and contact of partner company

Expected annual order volume

Equipment supplier or strategic partner

Any additional customer contracts

Financial Projections

Who prepared the projections (CPA?)

Production capacity assumptions

Price per unit

Gross margin assumptions

Revenue projections

Raw material sourcing

Employee headcount and labor cost

Working capital assumptions

Exit Strategy / Repayment Plan

Primary repayment source

When revenue starts

Revenue needed to break even

Refinance plan

Acquisition or exit strategy

Progressing...

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