Business Name*
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Business Address*
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Owner Name/Primary Contact
First name*
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Last name*
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Email address*
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Name of Owners with 20% equity or more
Owner 1
First name
Last name
Owner Address
Owner 2
First name
Last name
Owner Address
Owner 3
First name
Last name
Owner Address
Owner 4
First name
Last name
Owner Address
Business phone*
* x
Cell phone*
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Rent or Own Business Property?*
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Monthly Rent/Mortgage*
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EIN/SSN*
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Date Business Established*
Primary Industry (NAICS)*
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Ownership Structure*
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If Other, please specify
Number of Employees (Full Time Equivalent)*
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What type of loan are you requesting?*
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Reason and Purpose for Loan*
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Amount Requested*
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Do you have collateral that can be used to secure this loan?*
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If Yes, please list collateral that can be used to secure this loan
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Please download the Income and Expense Report below. Complete both worksheets for personal and business income and expenses. Once completed, please upload the file for review.*
Click
Here to download the Income and Expense Report
Please provide driver’s license for all owners.*
Please provide a copy of your most recently filed taxes*
Please list any current loans/credit cards or debts*
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Have you filed for bankruptcy within the last ten (10) years?*
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Are there any outstanding judgments entered against you?*
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Are you presently a party to any lawsuits?*
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Are there any local, state or federal tax liens filed against you?*
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Are you current with all municipal services, i.e. water, sewer?*
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Please indicate which represents you*
If Other, please specify
Are you current with all local, state, and federal taxes?*
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I understand that making a false statement on this form is a violation of law and could result in criminal prosecution, significant civil penalties, and a denial of the loan.*
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I am authorizing a credit bureau review*
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I understand a $50.00 application fee is required and my application will not be reviewed until fee is received.*
Checks should be made out to: "Erie County Redevelopment Authority" with "Microenterprise Fund Application" on the memo line.
Checks must be sent to:
Erie County Redevelopment Authority
ATTN: Ethan Bennett
1314 Griswold Plaza, Suite 200
Erie, PA 16501
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Signature*
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Please verify that you are a real person*