The Interbanc Group

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BUSINESS Loan Intake Sheet

Date:

Broker Name	Company	Cell#	Phone#	E-mail

Company / Project		Contact Name
Address		Cell Phone#
City, State & Zipcode		Fax#
Company Phone#		Email Address
Web Site

Type of Business Entity
	Corporation		Ltd. Partnership		Subchapter S Corp.
	Limited Liability Comp		Sole Proprietorship		General Partnership
	Individual (Business Purpose)		Trust		Other:

Business Activity
	Manufacturing		Retail		Professional
	Wholesale		Service		Government
	Franchise		Other:		Other:

Type of Industry Activity: $

State Incorp.

Date Incorp.

Type of Loan
	AR / Factoring		LOC		Standby LOC		Commercial Real Estate
	Term Loan		Mezzanine Funding		Inventory		Constructive Loan
	Bridge Loan		Leasing		Franchise		Acquisition
	Other:						Hard Money

Specific Loan Purpose
	Working Capital		Finance Purchase of Inventory		Finance Purchase of Equip
	Finance Purchase of Real Estate		Refinance Existing Loan or Debts		Finance Purchase of Bus
	Finance Accounts Receivable		Other:		Other:

Amount of Loan Requested: $

Requested Term of Loan:

Years

Year	Sales	Gross Profit	Operating Profit	Net Profit/ Loss	EBITDA	Interest Expense	CPLTD	LTD	Gross Profit Margin	Operating Profit Margin	5X EBITDA
											$
											$
											$
											$
											$

Inventory
Raw Materials	Work in Process	Finished Goods	TOTAL	Value @ 20%

Equipment & Fixed Assets
Original Cost	Book Value	Appraisal Value	Liens	Value @ 70%	Maturity Date

Current AR(>90 days):

AT 80%: $

Accounts Payable:

Own:

Rent:

Annual Rent:

Expir Date:

CAM Exp.

Extensions

PROCEEDS USE
	$ Amount
Real Estate Acquisition	$
New Construction Expansion/Repair	$
Acquisition	$
Inventory Purchase	$
Working Capital (including Loan Fees)	$
Acquisition of Existing Business	$
Payoff Bank Loan	$
Retire Long Term Debt:	$
Other:	$
Repair of Machinery & Equip.	$
TOTAL PROJECT	$
CAPITAL INJECTION / DOWN PMT.	$
LOAN AMOUNT	$

Guarantors Net Worth	$

COLLATERAL OFFERED
	Present Market Value	Present Loan Balance
Land	$	$
Building	$	$
Machinery & equipment	$	$
Furniture	$	$
Fixtures	$	$
Accounts Receivable	$	$
Inventory	$	$
Residential Real Estate	$	$
Other:	$	$
Other:	$	$
Other:	$	$
TOTAL	$	$


Guarantors Liquidity:	$