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Build :: Production :: [PGCAPP8]
Economic Development Incentive Fund
Ver. 1.6
Prince George's County, Maryland
Office of the County Executive
PLEASE KEY IN BASIC DETAILS ABOUT YOUR BUSINESS.
Business Name
*
Address 1
*
Address 2
City
*
State
Maryland
Zip
*
Phone
*
Email
*
Fax
Contact Person Name
*
Borrower(s)
Project Location
Municipality
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Collapse All
Basic Details
Assets/Liabilities
Notes Payable
Real Estate
Miscellaneous
BASIC DETAILS
Business Name
Owner Name
Social Security #
Date of Birth
Place of Birth (City,State/Country)
/
Percentage of Ownership
Residence Phone
Email Address
Citizenship
US Citizen
If No, Are you a Lawful Permanent resident alien
Lawful Permanent resident alien
If non-U.S. citizen, provide alien registration number:
Spouse Name
Spouse SSN
Present Residence Address Details
Most Recent Prior Address Details
From
From
To
To
Present Address
Prior Address
Assets
Liabilities
Cash on hand & in Banks
$
Credit Accounts (Schedule A)
$
Savings Accounts
$
Credit Accounts (Schedule A)
$
Retirement Accounts
$
Notes Payable (Schedule A)
$
Life Insurance - Cash Surrender Value Only
$
Installments (Auto)
$
Stocks and Bonds
$
Installments (Other)
$
Real Estate
$
Loan on Life Insurance
$
Automobile
$
Mortgages on Real Estate (Schedule B)
$
Value of Business
$
Home Equity Loans/Lines of Credit (Schedule B)
$
Other Personal Property
$
Unpaid Taxes
$
Other Assets
$
Other Liabilities
$
Accounts and Notes Payable (Schedule A)
Name
Address
Original Balance
Current Balance
Payment Amt.
Type of Collateral
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Real Estate (Schedule B)
Particular
Property A
Property B
Property C
Type of Property
(Pers. Resi.,Time-Share,Vaca./Rent. Property,Vacant Land)
Address
Date Purchased
Original Cost
Present Market Value
Name of Mortgage Holder
Mortgage Account Number
Current Mortgage Balance
Additional Lien Holder Name
Additional Lien Holder Amount
Amount of Payment per Month
Status of Mortgage
Most Recent Appraisal Date
Co-signor
Source of Income
Contingent Liabilities
Salary
$
As Endorser, Co-Signor, Guarantor
$
Spouse's Salary
$
Legal Claims & Judgement
$
Net Investment Income
$
Provisions for Federal Income Tax
$
Real Estate Income
$
Other Special Debt
$
Company Distributions
$
Other Income
$
Personal History
If you answer "Yes" to any of the following questions, furnish details on a separate sheet. Include dates, locations, fines, sentences, whether misdemeanor or felony, dates or parole/probation, unpaid fines or penalties, name(s) under which charged, and any other pertinent information. An arrest or conviction record will not necessarily disqualify you; however, untruthful answer will cause your application to be denied.
Are you presently under indictment, on parole or probation
Have you ever been convicted, placed on pretrial diversion, or placed on any form of probation, including adjudication withheld pending probation, for any criminal offence other than a minor vehicle violation.
Have you ever been charged with and/or arrested for any criminal offense other than a minor motor violation? Include offenses which have been dismissed, discharged, or not prosecuted. (All arrests and charges must be disclosed and explained on an attached sheet)
I authorize Prince George’s County to request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for programs authorized by the Small Business Act, and the Small Business Investment Act. Initials
Do you have any outstanding or unsatisfied judgments or liens?
Will both you and your spouse guaranty the debt?
IF No, Please explain:
I authorize Prince George’s County to make inquiries as necessary to verify the accuracy of the statements made and to determine my creditworthiness. I certify the above and statements contained in the attachments are true and accurate as of the stated date(s). These statements are made for the purpose of either obtaining a loan or guaranteeing a loan.