BORROWER INFORMATION

Legal Business Name

Tax ID#

D/B/A or Trade Name (if applicable)

Phone Number  

( )

Primary Business Address (Physical Street Address – no P.O. Box please)

City

State

Zip Code

Business Mailing Address (if different - i.e. P.O. Box)

City

State

Zip Code

Email

Description of Business / Products or Services Offered

Date Business Established

Current Ownership Since (Date)

State of  

Organization

LOAN REQUEST INFORMATION

Type of Loan

Amount

($10,000 - $250,000)

Overdraft Protection

Purpose of Loan

◻ Line of Credit

$

 Yes - Business Account #  __________________________

◻ Term Loan

$

◻ Commercial Mortgage

$

◻ Letter of Credit

$

BUSINESS DEPOSIT ACCOUNTS (Please attach a separate sheet if more space is needed)

Financial Institution

Account Type

Current Balance

BUSINESS DEBT (Please attach a separate sheet if more space is needed)

Financial Institution

Type of Loan

Current Balance

Collateral

Being paid off  with this loan?

$

◻ YES

◻ NO

$

◻ YES

◻ NO

COLLATERAL INFORMATION (Describe collateral offered to secure this loan) If cash or marketable securities, list separately below and provide  statements or stock certificates. For General Business Assets, list all addresses where the assets are located.

Collateral Description or Property Address

Purchase Price / Value

Prior Liens /  

Creditor

$

$

AUTHORIZATION AGREEMENT

The undersigned person(s) certifies that he/she has full authority to act on behalf of the business (the "Applicant") identified on the Business Loan Application  (the "Application), and that all information contained herein is true and correct in all respects. Webster Bank, N.A. (the "Bank") is hereby authorized to verify  any information provided in connection with the Application. The Bank may obtain credit reports for all owners / guarantors expected to be personally liable,  and may also do so for updates, renewals, extensions and any collection activity or as otherwise permitted by law. Under the federal Fair Credit Reporting  Act, the Bank may get or share information regarding the Applicant, guarantor(s) or Applicant's owner(s) with Bank affiliates unless the undersigned tells the  Bank not to share. The undersigned may prohibit the Bank from sharing information provided or obtained by the Bank from a third party, by mailing a written  request to Webster Bank, Business Banking, 609 West Johnson Avenue, Cheshire, CT 06410. The Application will be the Bank's property whether or not  credit is granted. Applicant agrees that the Bank may rely on a facsimile of the Application and any other signed documents received by the Bank by  facsimile transmission relating to the credit granted pursuant to the Application. Such facsimiles or any copy of such facsimiles shall be binding on Applicant  and shall for all purposes be considered original documents. The undersigned understands that making false statements or material omissions intended to  conceal pertinent facts may be a financial crime requiring referral to appropriate law enforcement officials. The undersigned further agree to notify the Bank  immediately of any change in name, address or employment, and any material change in (a) any of the information contained in the Application, or (b) the  financial condition of any of the undersigned, or (c) the ability of any of the undersigned to perform its or their obligations to the Bank. Applicant agrees that if  the Bank elects to include Applicant in the Bank's SBA (U.S. Small Business Administration) loan program, the Bank may submit an SBA loan application on  behalf of the Applicant using the information contained in the Application and other information obtained from the Applicant.

Applicant (Business) Legal Name (please print)

Officer / Member Signature

X

Title

Date

OWNERSHIP / GUARANTORS (Required for all individuals who own 25% or more of the Business – 20% or more for SBA guaranteed loans)

Name (Owner / Guarantor # 1)

% Ownership

Residential Address

City

State

Zip Code

D/O/B

Social Security #

Home Phone

( )

Gross Annual Income*

$

Name & Address of Employer / Date of Hire (if not employed by Borrower)

 Own Home Rent  

Monthly Payment: $ ____________

Time there: _______ Years _______ Months

Assets (excluding business)

Liabilities (excluding business)

Cash on Hand and in Banks

$

Notes Payable to Banks

$

Marketable Securities

$

Other Notes Payable

$

Loans/Notes Receivable

$

Accounts and Bills Payable

$

Real Estate Owned

$

Unpaid Taxes (Income and Real Estate)

$

Autos/Other Personal Property

$

Real Estate Mortgages

$

Cash Value Life Insurance

$

Other Liabilities

$

Retirement Funds

$

Other Assets

$

Total Liabilities

$

Net Worth (Total Assets minus Total Liabilities)

$

Total Assets

$

Total Liabilities and Net Worth

$

Name (Owner / Guarantor # 2)

% Ownership

Residential Address

City

State

Zip Code

D/O/B

Social Security #

Home Phone

( )

Gross Annual Income*

$

Name & Address of Employer / Date of Hire (if not employed by Borrower)

 Own Home Rent  

Monthly Payment: $ ____________

Time there: _______ Years _______ Months

Assets (excluding business)

Liabilities (excluding business)

Cash on Hand and in Banks

$

Notes Payable to Banks

$

Marketable Securities

$

Other Notes Payable

$

Loans/Notes Receivable

$

Accounts and Bills Payable

$

Real Estate Owned

$

Unpaid Taxes (Income and Real Estate)

$

Autos/Other Personal Property

$

Real Estate Mortgages

$

Cash Value Life Insurance

$

Other Liabilities

$

Retirement Funds

$

Other Assets

$

Total Liabilities

$

Net Worth (Total Assets minus Total Liabilities)

$

Total Assets

$

Total Liabilities and Net Worth

$

Owner / Guarantor (#1) Signature

X

Date

Owner / Guarantor (#2) Signature

X

Date

CUSTOMER IDENTIFICATION PROGRAM

In accordance with Section 326 of the USA PATRIOT Act, Webster Bank, N.A has developed a Customer Identification Program which is intended  to facilitate the prevention, detection and prosecution of international money laundering and the financing of terrorism. Section 326 of the Act  requires financial institutions to set forth minimum standards that relate to the identification and verification of any person who applies for an  

account. Under this Act a person is defined as any individual, corporation, partnership, trust, estate, association, syndicate and unincorporated  organization or group.

RIGHT TO RECEIVE A COPY OF APPRAISAL

For loans or lines of credit secured by a first lien on a residential dwelling, we may order an appraisal to determine the property’s value and  charge you for this appraisal. We will promptly provide you with a copy of any appraisals ordered, even if your loan does not close.

BUSINESS INFORMATION - REQUIRED  

(Please answer the following questions for each BUSINESS ENTITY involved with this loan. If more than one business, please use separate forms)

Do you operate this business at multiple locations? If yes, please list all address locations below (Street, City, State and Zip Code)

Primary geographic trade  

area (check all that apply)

◻ New York

◻ Connecticut

◻ International

◻ Massachusetts

◻ Other :______________

◻ Rhode Island

Is your business publicly  traded (Stock Exchange  listed)?

◻ Yes

◻ No

Is there any  

seasonality to your  business revenue? ◻ Yes

◻ No

Projected Sales growth over  next 12 months:

◻ Up to 10%

◻ 10-20%

◻ 20% or more

Do any of the following apply to either the Business or any owner/guarantor?

◻ Currently involved with any legal claims

◻ Been convicted of a felony

◻ Declared Bankruptcy (If yes, date: _________________)

◻ Contingently liable as a guarantor for other business debt

◻ Executive officer, director or principal shareholder of a financial  

◻ Owes past due taxes

institution?

Does / will your business perform any of the following services?

◻ Issue or sell money orders

◻ Exchange foreign currency or monetary instruments

◻ Issue or sell Traveler’s checks

◻ Provide money transfer services

◻ Sell or provide Prepaid Access Cards

◻ ATM Contractor services

◻ Cash checks for 3rd parties

◻ Internet Gambling

Have you or an immediate family member or close associate held any of the following positions:

⇒ Current or former senior foreign political figure: a foreign senior official in the executive, legislative, administrative, military  or judicial branches of a foreign government, whether elected or not?

⇒ Current or former senior foreign official of a major political party or a senior executive of a foreign government-owned  commercial enterprise, including a corporation, business or other entity formed by or for the benefit of such an individual?

Is there an ATM Machine located at your place of Business? If yes:  

~ Does / will your business own, operate or service ATMs?

~ Is the ATM located at your business leased?

~ Do you rent space in your Business to an ATM Contractor?

Monthly cash transactions anticipated with this loan account?

Payments – “Cash in”  

Advances – “Cash out”

◻ < $10,000

◻ < $10,000

◻ $10,001-$50,000

◻ $10,001-$50,000

◻ $50,001-$100,000

◻ $50,001-$100,000

◻ > $100,000

◻ > $100,000

◻ Yes

◻ Yes

◻ Yes

◻ Yes

◻ Yes

◻ Yes

◻ No

◻ No

◻ No

◻ No

◻ No

◻ No

Based on your answers to the questions above, you may be asked for additional information

OWNER / GUARANTOR - PERSONAL INFORMATION - REQUIRED  

(Please answer the following questions for each OWNER / GUARANTOR involved with this loan. If more than two people, please use separate forms)

Have you or an immediate family member or close associate held any of the following  positions:

⇒ Current or former senior foreign political figure: a foreign senior official in the executive, legislative, administrative, military or judicial branches of a foreign government, whether elected or not?

⇒ Current or former senior foreign official of a major political party or a senior executive of a foreign government-owned commercial enterprise, including a corporation, business  or other entity formed by or for the benefit of such an individual?

Are you a U.S. Citizen?  

⇒ If No, what is your country of citizenship? _______________________________ ⇒ If No, are you a Resident Alien or Non-Resident Alien? RA _____ NRA _____

Do you reside in a foreign country?  

⇒ If Yes, what country? _______________________________

Do you derive any personal income from outside the U.S.?

⇒ If Yes, what is the source of the income and from what country? _____________

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ Name & Address of Employer / Date of Hire (if not employed by the Borrower)

Guarantor # 1: ________________________________________________________ Guarantor # 2: ________________________________________________________

Owner / Guarantor # 1

Owner / Guarantor  # 2

◻ Yes

◻ Yes

◻ Yes

◻ Yes

◻ Yes

◻ No

◻ No

◻ No

◻ No

◻ No

◻ Yes

◻ Yes

◻ Yes

◻ Yes

◻ Yes

◻ No

◻ No

◻ No

◻ No

◻ No