EmailMeForm
HEALTHCARE FACILITY LOAN
Enter all amounts in $ USD.
This form is for any operating Healthcare Facility.
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.
Briefly describe what specific medical services the facility provides:
*
How much capital is the borrower seeking?
*
Specific breakdown of the use of the Loan proceeds:
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Where is the facility located?
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City/Town
State/Region
Country
All 3 Personal Credit Scores of the Principals (Equifax, Experian and TransUnion)
*
Equifax, Experian and TransUnion
Year company began:
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Net Collectable Accounts Receivable now (including patient self-pay):
*
Net Collectable Accounts Receivable over 150 days old:
*
Total Accounts Payable :
*
Approximately how much is being billed per month?
*
Approximately how much is collected per month?
*
What percentage (%) of Overall Receivables is:
*
No Fault
From Medicare
From Medicaid
From Commercial Carries
Are there any tax deliquencies?
*
Yes
No
What is current facility net worth?
*
Are Accounts Receivable currently encumbered by a lien?
*
Yes
No
If Yes, what amount:
*
If No, enter "0"
2023 Revenue:
*
2023 Net Income:
*
2022 Revenue:
*
2022 Net Income:
*
2021 Revenue:
*
2021 Net Income:
*
This year's Projected Sales Volume:
*
Is the borrowing entity currently making money?
*
Yes
No
If making money, for how many consecutive months?
*
if not making money, enter "0"
Does the borrowing entity have accountant prepared financial statements?
*
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 facility equipment if it had to be liquidated:
*
Appraised or Estimated value of business owned Real Estate:
*
Total secured debt (including mortgage) against company now:
*
Monthly payment now on secured debt:
*
Are the payments current?
*
Yes
No
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.
3 Years Financial Statements
Real Estate Owned Schedule (REO)
Detailed Budget
Other:
Signature
Name of person completing form:
*
Phone:
*
Email:
*
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.
