Business Name*

Business Address*

First name*

Last name*

Email address*

First name

Last name

Owner Address

First name

Last name

Owner Address

First name

Last name

Owner Address

First name

Last name

Owner Address

Business phone*

Cell phone*

Rent or Own Business Property?*

Monthly Rent/Mortgage*

EIN/SSN*

Date Business Established*

Primary Industry (NAICS)*

Ownership Structure*

Number of Employees (Full Time Equivalent)*

What type of loan are you requesting?*

Reason and Purpose for Loan*

Amount Requested*

Do you have collateral that can be used to secure this loan?*

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.*

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*

Have you filed for bankruptcy within the last ten (10) years?*

Are there any outstanding judgments entered against you?*

Are you presently a party to any lawsuits?*

Are there any local, state or federal tax liens filed against you?*

Are you current with all municipal services, i.e. water, sewer?*

Please indicate which represents you*

Are you current with all local, state, and federal taxes?*

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.*

I am authorizing a credit bureau review*

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 "Small Business 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

Signature*