EmailMeForm
HEALTHCARE FACILITY ACQUISITION LOAN
.
"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:
*
Enter all amounts in USD $ Only
Cash equity from buyer:
*
Down Payment
Note to be held by seller (if any)
Total Loan Amount Requested:
*
All 3 Personal Credit Scores of the Buyers (Equifax, Experian and TransUnion)
Equifax, Experian and TransUnion
Is the Buyer:
*
Individual
Existing Company (LLC, Corp, etc)
Other (please explain)
QUESTIONS PERTAINING TO THE HEALTHCARE FACILITY TO BE ACQUIRED
Where is the facility to be acquired located?
*
City/Town
State/Region
Country
When did this facility begin operations?
*
Description of Healthcare Facility to be acquired
*
(Services offered, etc.)
Net Collectable Accounts Receivable now (excluding patient self pay):
*
Net Collectable Accounts Receivable over 150 days old:
*
Total Accounts Payable now:
*
Approximately how much is Billed per month?
*
Approximately how much is Collected per month?
*
What percentage (%) of Overall Receivables is:
No Fault
From Medicare
From Medicaid
From Commercial Carriers
Are there any tax delinquencies?
*
Yes
No
What is the current company net worth?
*
Are the Accounts Receivable currently encumbered?
*
Yes
No
If encumbered, by whom and for what amount?
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?
Does the seller 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 liquidation value of Equipment if it were liquidated:
*
furniture and telephone/computer equipment is not acceptable collateral
Appraised/Estimated value of business owned Real Estate:
*
Total secured debt (including mortgage) against facility now:
*
Why is the facility being sold?
*
Does the buyer have direct experience with respect to the type of business being acquired and if so for how long?
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
Project Summary
Detailed Construction or Rehab Budget
Personal Net Worth Statement (PNW)
Real Estate Owned Schedule (REO)
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.
