Business / English

Business Loan Preapplication

Use this form to give Derivitas a preliminary view of the business, the objective and the requested capital. Save sensitive records for a secure follow-up.

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Do not fill this out:

01 Contact and request

Applicant full legal name * Email * Phone * Last four digits of SSN

Last four only. Do not submit your full Social Security number.

Amount requested * When are funds needed? * Preferred financing Preferred repayment term Use of funds and estimated amount for each use * Owner funds available

02 Borrowing business

Legal business name * DBA or trade name Entity type * State formed * Business start date * Website Business address * Industry and primary products or services * Full-time employees Part-time employees Operating location

03 Financial snapshot

Most recent completed tax year * Revenue for that year * Net profit or loss for that year * Prior-year revenue Prior-year net profit or loss YTD period ending YTD revenue YTD net profit or loss Average monthly revenue, last 6 months * Average monthly operating expenses * Business cash currently available Monthly business debt payments Expected repayment source and any seasonal changes

04 Ownership and guarantor

Primary owner's title * Primary ownership percentage * Additional owner 1 name Additional owner 1 percentage Additional owner 2 name Additional owner 2 percentage Primary owner's occupation or employer Years in current work Annual employment income Annual income from this business Other annual income Estimated credit score range Monthly housing payment Other monthly personal debt Cash available for business investment Potential collateral, estimated value and known liens

05 Current obligations

List major business obligations. Do not include account numbers.

Obligation 1

Lender and typeCurrent balancePayment and frequencyMaturity or collateral

Obligation 2

Lender and typeCurrent balancePayment and frequencyMaturity or collateral

Obligation 3

Lender and typeCurrent balancePayment and frequencyMaturity or collateral

Other companies owned, including ownership percentage, annual revenue, profit and monthly debt

06 Initial screening

Any outstanding SBA or other government loans? *

Yes No

Any past-due debts, tax liens or unpaid taxes? *

Yes No

Any bankruptcy, foreclosure or default in the last 7 years? *

Yes No

Any pending lawsuit or judgment? *

Yes No

Explain any yes answers

07 Records available

Check what you can provide later through an agreed secure method. Do not upload or email these records now.

Business tax returns, 2 to 3 yearsPersonal tax returns, 2 to 3 yearsBusiness bank statements, 6 monthsCurrent profit and loss statement and balance sheetDebt schedule and statementsOwnership and formation documentsQuotes, purchase agreement or use-of-funds supportFinancial projections

08 Acknowledgement

This is a preliminary request for information. It is not a credit application, offer, approval or commitment to provide financing. Derivitas Group is not a lender and does not make credit decisions. Any provider independently determines eligibility, underwriting, rates, fees and terms.

By submitting, I confirm that the information is accurate to the best of my knowledge and authorize Derivitas to contact me about this request and share the information with relevant independent financing providers when appropriate.

Typed full name *Date *

I have read and agree to the acknowledgement above. *

Your information will be submitted to Derivitas for preliminary review.