THE HELP PROGRAM APPLICATION FORM

I. Summary Information:

Borrower Name:__________________________________________
Borrower Address:________________________________________
Address of Project (if different from borrower):
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Contact Person:______________________ Title:_______________
Phone:_______________________ Fax:______________________
E-Mail:_________________________________________________
Requested Loan Amount (max. $500,000):____________________
Requested Term (max. 10 years):___________________________
Proposed Collateral:______________________________________
Date of Application:_______________________________________
Date Funds Needed:_______________________________________

[Authority Use Only]
Date Received:_________________ Authority Meeting Date:_________________

II. General Eligibility:

		Yes	No
A.	Is borrower considered an eligible health or educational facility pursuant to the General Requirements listed on page one of the Information Material and Pursuant to the Authority’s Act?	_____	_____
	State type of eligible facility: ____________________________
B.	Has the borrower been in existence for at least three years performing the same type of services?	_____	_____
C.	If construction or remodeling is part of the project, is work ready to begin upon funding? (i.e., construction contract executed and building permit obtained)	_____	_____
	*If answer to C is no, please provide brief status report below: _________________________________________________________ _________________________________________________________ _________________________________________________________
D.	If the answer to C is no, will a portion of the loan funds be used to pay for studies or other necessary pre-construction costs?	_____	_____
E.	Are your services available to all who reside and work in your service area?	_____	_____

III. Background Information: (Use additional pages as necessary)

A. Describe your organization’s mission and history. What programs do you provide? How long have you been providing them?
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IV. Explanation of the Project:

A. Describe the project (i.e. building, equipment, acquisition or other capital projects, etc.) for which funds are requested and how the project will assist Missouri residents.
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V. Sources and Uses of Funds:

A. Sources of Funds:
	HELP! Loan	$______________	(_________%)
	Borrower Funds	$______________	(_________%)
	Other (describe)
	__________________________	$______________	(_________%)
	__________________________	$______________	(_________%)
	__________________________	$______________	(_________%)
	Total Sources:	$______________	(______100%)
	“Borrower Funds” must comprise at least ten percent (10%) of the total sources of funds. This ten percent (10%) must either be in the form of cash or documented project expenditures, subject to approval by the Authority.
B. Uses of Funds:
	Construction (new or remodeling)	$______________
	Acquisition of real property	$______________
	Equipment	$______________
	Authority closing fee (.5% of loan amount)	$______________
	Other (list)
	__________________________	$______________
	__________________________	$______________
	__________________________	$______________
	__________________________	$______________
	Total Uses:	$______________
C. Description of Proposed Collateral:
	__________________________ __________________________

VI. Supplemental Materials:

1. Corporate Status:

Provide a copy of the operating license(s) of the facility(s) to receive financing.
Provide copies of your corporation’s certified Articles of Incorporation and Bylaws and any changes since the initial filings.
Provide a copy of the most recent accreditation letter, if applicable.

2. Financial Information:

Provide copies of audited financial statements for the three most recent fiscal years, and the most recent unaudited interim statements.
Current operating budget, including utilization (health) or enrollment (education) statistics for the past three years.
Discuss any significant year-to-year changes in net income, assets and liabilities.
Provide a copy of Board Minutes or resolution approving the application for a loan for this project.

3. Management Information:

List the names, terms, and occupations of your corporation’s Board of Directors.

4. Other Information:

State whether there exists any suit or proceeding, pending or threatened, which might adversely affect your ability to operate or to repay the loan. Use additional pages and attach supporting documentation if necessary.
Note any delinquent tax obligations and if all tax returns have been filed. Use additional pages and attach supporting documentation if necessary.

5. Certification:

Please have the Executive Director, CEO, Chair of the Board or other individual with the authority to commit the organization to contract complete the following certification.

I certify that to the best of my knowledge the information contained in this application and the accompanying supplemental materials is true and accurate.

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Print Name	Signature

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Title	Date

Revised January 11, 2017