Part
A – Background Information
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1
Lender
Name and Address
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Enter
Lender Institution’s name and complete mailing address.
Also include physical address if different from mailing address.
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2
Lender
Tax ID
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Enter
Lender Institution’s 9 digit tax identification number.
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3
Telephone
No.
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Enter
Lender Institution’s telephone number including area code.
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4
Regulatory
or Certifying Agency
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Enter
the name of the Lender’s regulatory or certifying agency.
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5
Lender
Type
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Enter
lender type. e.g. Credit union, CDFI, RRC, commercial bank,
savings bank, etc.
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6
Primary
Contact Name
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Enter
the name of the primary contact for the Lender.
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7
Primary
Contact Title
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Enter
the title of the primary contact for the Lender.
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8
Primary
Contact Telephone No.
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Enter
the telephone number of the primary contact for the Lender.
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9
Primary
Contact Email Address
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Enter
email address of the primary contact for the Lender.
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10
Lender
Organizational Structure
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Describe
such things as type of entity, key positions, number of years of
experience, vision, mission, stakeholders, target loan
recipients, geographical territory covered, etc.
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11
Source
of Fund
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Describe
various sources of funding that will be used for FSA EZ
Guarantees.
(Micro Lenders can underwrite FSA EZ Guarantees of $50,000 or
less).
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12
Type
of Loans
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Check
the box(s) that corresponds to the type of loans the Lender
Institution anticipates submitting to FSA for guarantee.
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Part
B – Lender Financial Information
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13
Total
Assets
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Enter
the Lender Institution’s total assets.
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14
Loans
Receivable
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Enter
Lender Institution’s loans receivable principal balance.
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15
Loan
Loss Reserves
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Enter
amount Lender Institution is holding in reserve to cover losses.
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16
Total
Liabilities
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Enter
the amount of the Lender Institution’s total liabilities.
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17
Net
Assets
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Enter
amount of the Lender Institution’s net assets.
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Part
C – Business Loan Activity and Portfolio
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18
Operating
Lines of Credit
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Enter
total:
#
of operating lines of credit closed.
#
of operating lines of credit $50,000 or less closed.
$
amount of operating lines of credit $50,000 or less closed in
the past 7 years.
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19
Intermediate
Term Loans
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Enter
total:
#
of intermediate term loans closed.
#
of intermediate term loans $50,000 or less closed.
$
amount of intermediate term loans $50,000 or less closed in the
past 7 years.
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20
Real
Estate Loan
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Enter
total:
#
of real estate loans closed.
#
of real estate loans $50,000 or less closed.
$
amount of real estate loans $50,000 or less closed in the past 7
years.
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21
Total
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Enter
total:
#
of all loans closed.
#
of all loans $50,000 or less closed.
$
amount of all loans $50,000 or less closed in the past 7 years.
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Part
D – Business Loan Performance
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22
Operating
Lines of Credit
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Enter
total:
%
of operating lines of credit that are currently delinquent.
%
of outstanding principal balance of operating lines of credit
currently delinquent.
$
amount settled or written off on operating lines of credit of
$50,000 or less that were made in the past 7 years.
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23
Intermediate
Term Loans
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Enter
total:
%
of intermediate term loans that are currently delinquent.
%
of outstanding principal balance of intermediate term loans
currently delinquent.
$
amount settled or written off on intermediate term loans of
$50,000 or less that were made in the past 7 years.
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24
Real
Estate Loans
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Enter
total:
%
of real estate loans that are currently delinquent
%
of outstanding principal balance of real estate loans currently
delinquent.
$
amount settled or written off on real estate loans of $50,000 or
less that were made in the past 7 years.
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25
Total
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Enter
total:
%
of all business loans that are currently delinquent.
%
of outstanding principal balance of all business loans currently
delinquent.
$
amount settled or written off on all business loans of $50,000
or less that were made in the past 7 years.
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Part
E – Staff
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26
Staff
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Describe
the staff that will be underwriting and servicing EZ guarantees.
Include such things as number of staff, title, responsibility,
years of experience.
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Part
F – Lender Certification
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27A
Name
of Lender’s Representative
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Print
the legal name of the Lender’s representative.
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27B
Title
of Lender’s Representative
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Enter
the title of the Lender’s representative.
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28A
Representative’s
Signature
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Enter
the signature of the Lender’s representative.
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28B
Date
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Enter
date signed by the Lender’s representative.
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