EmailMeForm
ACQUISITION OF A HEALTHCARE BUSINESS
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"SEE ATTACHED" IS NOT AN ACCEPTABLE ANSWER. ALL FIELDS MUST BE COMPLETE.
Submissions that state “See Attached” or have missing information will be considered incomplete and applicant will be required to re-submit the form.
Enter all amounts in $USD.
Purchase Price of Business:
*
Enter all amounts in USD $ Only
Seller Note (if any)
Cash Equity from Buyer:
*
Down Payment
Loan Request:
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Personal Credit Scores of the Buyer(s):
*
Is the Buyer:
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Individual
Existing Company (LLC, Corp, etc)
Other (please explain)
Does the buyer have direct experience with respect to the type of business being acquired and if so for how long?
Questions Pertaining to the Healthcare Business to be Acquired:
Briefly describe what specific medical services the business provides:
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Where is the company to be purchased located?
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City/Town
State/Region
Country
Year company began:
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Net Collectable Accounts Receivable now (including patient self-pay):
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Net Collectable Accounts Receivable over 150 days old:
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Total Accounts Payable now:
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Total Accounts Payable over 150 days old:
*
Approximately how much is collected per month?
*
What percentage (%) of Overall Receivables is:
No Fault
From Medicare
From Medicaid
From Commercial Carriers
Are there are tax delinguencies?
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Yes
No
What is the current company net worth?
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Are Accounts Receivables currently encumbered by a lien?
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Yes
No
If Yes, what amount?
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2023 Revenue:
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2023 Net Income:
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2022 Revenue:
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2022 Net Income:
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2021 Net Income:
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2021 Revenue:
*
This year's projected sales volume:
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Is the business currently making money?
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Yes
No
If making money, for how many consecutive months?
if not making money, enter 0
Does the business have accountant prepared financial statements?
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Yes
No
If so, when does the accounting year end?
What type of statement?
Select One
Audited
Reviewed
Compiled
No Statements Available
Estimate the value of business equipment if it had to be liquidated:
*
furniture and telephone/computer equipment is not acceptable collateral
Appraised or Estimated value of business owned Real Estate:
*
Total secured debt (including mortgage) against company now:
*
Monthly payment on secured debt now:
*
Are the paymetns current?
*
Yes
No
Why is the business being sold?
*
Additional Comments, if any:
Optional File Upload
ALL QUESTIONS MUST BE ANSWERED
Submissions that state “See Attached” or have missing information will be considered incomplete and applicant will be required to re-submit the form.
Resumes
Personal Net Worth Statement (PNW)
Detailed Budget
Real Estate Owned Schedule (REO)
3 Years Personal Tax Returns of the borrower
Other
Signature
Name of person completing form:
*
Phone:
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Email:
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Confirm
Person completing the form is:
*
Broker
Principal Borrower(s)
Other
Referral Information (if applicable)
Name of person who referred you to us:
Email of person who referred you to us:
Account Executive (if applicable)
If you have been assigned an Account Executive (other than the person who referred you), please enter their email here.
