RMI Disaster Business Loan Application

SUBMISSION REQUIREMENTS

APPLICANT INFORMATION

Applicant’s Legal Name Phone ( )

Mailing Address

Email Address

Trade Name (if different from legal name) Federal EIN

Damaged Property Address (es) (if more space needed, attach additional sheets)

Business Property (Please circle one): Owned Leased

Type of Business

1. Copies of the applicant’s 3 most recent Federal Income Tax Returns, including all schedules. If this is a new business that has not filed 3 Federal Tax Returns, submit the ones you have filed. Also, complete and sign the attached Tax Information Authorization (IRS form 8821). Sole proprietors need only submit the IRS Form 8821. We will contact you if we need additional information. (i.e., forecasts, etc.).

2. A current (dated within 90 days of application) business balance sheet (you may use the attached Personal Financial Statement, if you are a sole proprietorship), a current profit and loss statement, and a current schedule of liabilities. (We attached a sample schedule of liabilities for your convenience.) 3. For each owner having a 20% or more interest and each general partner, a current (dated within 90 days of application) Personal Financial Statement, a complete copy, including all schedules, of the most recent Federal Income Tax Return and a complete and signed IRS Form 8821. Individuals with an ownership interest need only supply an IRS Form 8821 and a Personal Financial Statement.

4. A complete copy , including all schedules, of the latest Federal Income Tax Return for each affiliate. Affiliates include, but are not limited to, business parents, subsidiaries or other businesses with common ownership or management. Also, you must have an authorized individual complete and sign the attached IRS Form 8821 for each affiliate.

5. If your insurance covers all or a part of this loss (regardless of the current status of your claim), please provide the name and telephone number of your agent and/or claims adjuster. Also, include the policy number and the name of the insurance company.

Street Address City County State ZIP

Street Address City County State ZIP

Under Current Management Since:

Date Established Number of Employees

Amount of Loan Request (if unknown, enter question mark)

Management (if more space needed, attach additional sheets)

1. Name Social Security No.

Title/Office Phone ( )

Date of Birth Place of Birth

2. Name Social Security No.

Title/Office Phone ( )

Date of Birth Place of Birth

For each individual listed in Management, please respond to the following questions, providing dates and details. (if more space needed, attach additional sheets)

a. Has never been involved in bankruptcy or insolvency proceedings, expect as stated:

b. Has no outstanding judgments, tax liens, or pending lawsuits against them, except as stated:

c. Has not been convicted or a criminal offense committed during and in connection with a riot or civil disorder, nor is such person or the applicant engaged in the production or distribution of any product or service that has been determined to be obscene by a court of competent jurisdiction, except as stated:

d. Has never had any Federal Loans or Federally guaranteed loans, except as stated:

e. Is not delinquent on any Federal taxes, direct or guaranteed loans (SBA, FHA, VA, student, etc.), contracts, grants, state taxes or any child support payments, except as stated:

Complete for each 1) Proprietor, or 2) limited Partner who owns 20% or more interest and general partner, or 3) stockholder owning 20% or more voting stock

Are any of the individuals listed in Management, (a) presently under indictment, on parole or probation, or have they been: (b) charged with or arrested for any criminal offense (including offenses which have been dismissed, discharged, or not prosecuted) other than a minor motor vehicle violation; or (c) convicted, places on pretrial diversion, or placed on any form of probation including adjudication withheld pending probation for any criminal offense other than a minor motor vehicle violation? • YES • NO

If you are a sole proprietor, are you a U.S. citizen? • YES • NO

Organization type • Sole Proprietorship • Partnering • Limited Proprietorship • Corporation • Other

AUTHORIZATION

• Yes, I authorize the release to RMI any information they may require at any time for any purpose related to my/our credit transaction with them. By checking the Yes box above and submitting this form, I further authorize RMI to release such information to any entity they deem necessary for any purpose related to my/our credit transaction with them.

I/We authorize RMI to obtain a credit report on me/us through the credit reporting agency of its choice, as well as to answer questions others may ask about my/our credit record with RMI.

I/We understand that I/We must update credit and financial information as requested if my/our financial condition changes.

I/We certify that the above information, including any attachments or exhibits provided her with in or at a later date, is valid and correct to the be of my/our knowledge

Print Name

Signature Date

Print Name

Signature Date

06/19

SCHEDULE OF DEBT

CreditorName&Address

OriginalAmount

OriginalDate

PresentBalance

InterestRate

MaturityDate

MonthlyPayment

Collateral

LINE OF CREDIT INFORMATION

Section 2. Notes Payable to Bank and Others.*Alimony or child support payments need not be disclosed in "Other Income" unless it is desired to have such payments counted toward total income.

(Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.)

Description of Other Income in Section 1.

Section 1.

(Describe in Section 2)

Mo. Payments

Mo. Payments

(Describe in Section 4)

(Describe in Section 6)

(Describe in Section 7)

LIABILITIES

(Complete Section 8)

(Describe in Section 3)

(Describe in Section 4)

(Describe in Section 5)

(Describe in Section 5)

Cash on hands & in BanksSavings AccountsIRA or Other Retirement AccountAccounts & Notes ReceivableLife Insurance-Cash Surrender Value Only

Stocks and Bonds

Real Estate

Automobile-Present ValueOther Personal Property

Other Assets

ASSETS

PERSONAL FINANCIAL STATEMENT

As of , 20

Complete this form for: (1) each proprietor, or (2) each limited partner who owns 20% or more interest and each general partner, or (3) each stockholder owning20% or more of voting stock, or (4) any person or entity providing a guaranty on the loan.

Name Business Phone

Residence Address Residence Phone

City, State, & Zip Code

Business Name of Applicant/Borrower

(Omit Cents)(Omit Cents)

Accounts PayableNotes Payable to Banks and Others

Installment Account (Auto)

Installment Account (Other)

Loan on Life InsuranceMortgages on Real Estate

Unpaid Taxes

Other Liabilities

Total LiabilitiesNet Worth

TotalTotalContingent Liabilities

As Endorser or Co-MakerLegal Claims & JudgmentsProvision for Federal Income TaxOther Special Debt

SalaryNet Investment IncomeReal Estate IncomeOther Income (Describe below)*

Source of Income

Name and Address of Noteholder(s) How Secured or EndorsedType of Collateral

(tumble)

Frequency(monthly,etc.)

OriginalBalance

CurrentBalance

PaymentAmount

$$$$$

$

$

$$

$

$

$$

$$

$$

$$

$

$

$$$

$$$$

$$$$

(List each parcel separately. Use attachment if necessary. Each attachment must be identified as a partof this statement and signed.)

Property A Property B Property C

Type of Property

Address

Date Purchased

Original Cost

Present Market Value

Name &Address of Mortgage Holder

Mortgage Account Number

Mortgage Balance

Amount of Payment per Month/Year

Status of Mortgage

Section 8. Life Insurance Held. (Give face amount and cash surrender value of policies - name of insurance company and beneficiaries)

Section 7. Other Liabilities. (Describe in detail.)

Section 6. Unpaid Taxes. (Describe in detail, as to type, to whom payable, when due, amount, and to what property, if any, a tax lien attaches.)

(Describe, and if any is pledged as security, state name and address of lien holder, amount of lien, termsof payment and if delinquent, describe delinquency)

Section 3.

I authorize RMI to make inquiries as necessary to verify the accuracy of the statements made and to determine my creditworthiness. I certify the aboveand the statements contained in the attachments are true and accurate as of the stated date(s). These statements are made for the purpose of either obtaininga loan or guaranteeing a loan. I understand FALSE statements may result in forfeiture of benefits and possible prosecution by the U.S. Attorney General(Reference 18 U.S.C. 1001).

Signature: Date: Social Security Number:

Signature: Date: Social Security Number:

Number of Shares Name of Securities Cost Market ValueQuotation/Exchange

Date ofQuotation/Exchange Total Value

Section 5.

Section 4.

assistance must submit this form in TRIPLICATE for filing with the RMI application.

STATEMENT OF PERSONAL HISTORY

Please Read Carefully - Print or TypeEach member of the small business concern or the development company requesting

This form must be filled out and submitted by:

Name and Address of Applicant (Firm Name)(Street, City, State, and ZIP Code) RMI Area Office

Amount Applied for (when applicable) File No. (if known)

1. Personal Statement of: (State name in full, if no middle name, state (NMN), or if initialonly, indicate initial.) List all former names used, and dates each name was used.Use separate sheet if necessary.

First Middle Last

Name and Address of participating lender or surety co. (when applicable and known)

2. Date of Birth (Month, day, and year)

3. Place of Birth: (City & State or Foreign Country)

U.S. Citizen? YES NOIf no, give alien registration number:

4. Give the percentage of ownership or stock owned orto be owned in the small business concern or theDevelopment Company

Social Security No.

5.

Address:

Present residence address:From:

To:

Home Telephone No. (Include A/C):

Business Telephone No. (Include A/C):

Address:

Most recent prior address (omit if over 10 years ago):From:

To:

IT IS AGAINST RMI'S POLICY TO PROVIDE ASSISTANCE TO PERSONS NOT OF GOOD CHARACTER; THEREFORE, CONSIDERATION IS GIVEN TO APERSON'S BEHAVIOR, INTEGRITY, CANDOR, AND DISPOSITION TOWARD CRIMINAL ACTIONS. IT IS ALSO AGAINST RMI'S POLICY TO PROVIDEASSISTANCE NOT IN THE BEST INTEREST OF THE UNITED STATES; FOR EXAMPLE, IF THERE IS REASON TO BELIEVE THE EFFECT OF SUCHASSISTANCE WILL BE TO ENCOURAGE OR SUPPORT, DIRECTLY OR INDIRECTLY, ACTIVITIES HARMFUL TO THE SECURITY OF THE UNITEDSTATES.

THEREFORE, IT IS IMPORTANT THAT THE NEXT THREE QUESTIONS BE ANSWERED TRUTHFULLY AND COMPLETELY. AN ARREST ORCONVICTION RECORD WILL NOT NECESSARILY DISQUALIFY YOU; HOWEVER, AN UNTRUTHFUL ANSWER WILL CAUSE YOUR APPLICATION TO BEDENIED.

IF YOU ANSWER "YES" TO 6, 7, OR 8, FURNISH DETAILS IN A SEPARATE EXHIBIT. INCLUDE DATES, LOCATION, FINES, SENTENCES, WHETHERMISDEMEANOR OR FELONY, DATES OF PAROLE/PROBATION, UNPAID FINES OR PENALTIES, NAME(S) UNDER WHICH CHARGED, AND ANY OTHERPERTINENT INFORMATION.6. Are you presently under indictment, on parole or probation?

Yes No (If yes, indicate date parole or probation is to expire.)

7. Have you ever been charged with and or arrested for any criminal offense other than a minor motor vehicle violation? Include offenses which have been dismissed, discharged, or not prosecuted (All arrests and charges must be disclosed and explained on an attached sheet.)

Yes No

8. Have you ever been convicted, placed on pretrial diversion, or placed on any form of probation, including adjudication withheld pending probation, for any criminal offense other than a minor vehicle violation?

Yes No

CAUTION: Knowingly making a false statement on this form is a violation of Federal law and could result in criminal prosecution, significant civil penalties, and a denial of your loan,surety bond, or other program participation. A false statement is punishable under 18 USC 1001 by imprisonment of not more than five years and/or a fine of not more than $10,000;under 15 USC 645 by imprisonment of not more than two years and/or a fine of not more than $5,000; and, if submitted to a Federally insured institution, under 18 USC 1014 byimprisonment of not more than twenty years and/or a fine of not more than $1,000,000.

Signature Title Date

1.2.3.

4.

If a sole proprietorship by the proprietor.If a partnership by each partner.If a corporation or a development company, by each officer, director, and additionally by each holder of 20% or more of the voting stock.Any other person including a hired manager, who has authority to speak for and committhe borrower in the management of the business.

COLLATERAL FORM

Item Description Serial # Purchase Item or Existing Item Value $