Personal Information Supplement | Micro Loans for Business Owners and Entrepreneurs in MD

This document in its entirety must be completed by all borrowers to be listed on the loan.
ALL blanks MUST be completed, if not applicable enter either N/A or for numeric values enter 0.

Section 1: General Application Information

1-1 Applicant Information

Business Name

Applicant Name

First Last

Driver’s License #

Please upload a picture of your driver's license*

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.

State

Expiration

Address

Street Address City State ZIP Code

Home Phone

Cell Phone

(if different from Home Phone)

Date of Birth

Social Security # of Applicant(s)

Email Address

Are you a US citizen?

Yes
No

Veteran?

Yes
No

If no, please provide proof of residency

Max. file size: 50 MB.

1-2 Employment Information (if currently employed)

Employment Status:

Full Time Self Employment
Full Time Employment
Part Time Self Employment
Part Time Employment
Seasonal Employment
Unemployed

Employer Name

Phone

Address

Street Address City State ZIP Code

Date Employed From

Date Employed To

Supervisor Name

Current Salary

Salary

Pay Frequency

Section 2: Personal Financial Information

2-1 Personal Financial Information

Complete each section in its entirety (if not applicable, enter a zero (0)) or attach a financial statement (only if done within the past 30 days). Please also attach your prior two (2) years of tax return filings.

Net Worth*

Description of Other Income*

Please also attach your prior two (2) years of tax return filings*

Drop files here or

Max. file size: 50 MB.

2-2 Notes Payable Detailed (Money owed to another party). (Enter N/A or 0 if not applicable)

Name of Noteholder*

First Last

Address of Noteholder*

Street Address City State ZIP Code

Original Balance*

Current Balance*

Payment Amount*

Frequency*

How is the note secured or endorsed. Type of collateral.*

Name of Noteholder

First Last

Address of Noteholder

Street Address City State ZIP Code

Original Balance

Current Balance

Payment Amount]

Frequency

How is the note secured or endorsed. Type of collateral.

If more than 2, upload additional ones here

Max. file size: 50 MB.

2-3 Stocks and Bonds Detailed

If more than 2 please upload an additional sheet.

I have Stocks and Bonds*

Yes
No

Number of Shares

Name of Securities

Market Value

Date of Valuation

NumberTotal Value

Number of Shares

Name of Securities

Market Value

Date of Valuation

Total Value

If more than 2 please upload an additional sheet here

Max. file size: 50 MB.

2-4 Real Estate Owned

If more than 1 property, attach an additional sheet.

I own Real Estate*

Yes
No

Type of Property

Date Purchased

Address

Street Address City State ZIP Code

Original Cost

Current Market Value

Name of Mortgage Holder

Mortgage Account Number

Address of Mortgage Holder

Street Address City State ZIP Code

Mortgage Balance

Monthly Payment Status of Mortgage

If more than 1 property, attach an additional sheet here

Max. file size: 50 MB.

2-5 Other Personal Property and Other Assets (Enter N/A if not applicable)

Describe, and if any is pledged as security, state name and address of lien holder, amount of lien, terms of payment and if delinquent, describe.

2-6 Unpaid Taxes (Enter N/A if not applicable)

Describe in detail, as to type, to whom payable, when due, amount, and to what property, if any, a tax lien attaches.

2-7 Other Liabilities (Enter N/A if not applicable)

Describe in detail any other liabilities, not mentioned elsewhere.

2-8 Life Insurance Held (Enter N/A if not applicable)

Give face amount and cash surrender value of policies – name of insurance company and beneficiaries.

2-9 Household Expenses (Monthly)

Please provide detailed expenses incurring on a monthly basis. (Enter "0" if not applicable)

Rent/Mortgage

Auto Payment(s)

Insurance (Auto, Homeowners, Life, etc.)

Phone (Cell and/or Landline)

Electric

Gas

Water/Sewer/Trash

Cable/Direct TV

Internet

Groceries

Misc. (Eating out, Entertainment, Etc.)

Credit Card Payments

Student Loan Payments

Personal Loan Payments

Additional Expenses

Please Clarify Additional Expenses

Total Monthly Expenses

Section 3: References

3-1 Please provide 3 personal references and their contact information. (All spaces must be completed)

Name*

Phone*

Relationship*

Address*

Street Address City State ZIP Code

Name*

Phone*

Relationship*

Address*

Street Address City State ZIP Code

Name*

Phone*

Relationship*

Address*

Street Address City State ZIP Code

Section 4: Alternate Contact Information

4-1 List two people through whom you can usually be contacted if we have trouble reaching you (we will not contact these people for any other reason) All spaces MUST be completed:

Name*

Phone*

Relationship*

Address*

Street Address City State ZIP Code

Name*

Phone*

Relationship*

Address*

Street Address City State ZIP Code

Section 5: Acknowledgement

5-1 Conditions

Signature*

I authorize MCE to make inquiries as necessary to verify the accuracy of the statements made and to determine my creditworthiness. MCE reserves the right to pull periodic credit reports during the repayment of the loan. I certify the above and the statements contained in the attachments are true and accurate as of the stated date(s). These statements are made for the purpose of either obtaining a loan or guaranteeing a loan. I understand FALSE statements may result in forfeiture of benefits and possible prosecution by the U.S. Attorney General. (Reference 18 U.S.C. 1001).

Printed Name*

Date*

Social Security*

Date of Birth*

Signing as Borrower, Guarantor or Both?*

Name

This field is for validation purposes and should be left unchanged.