INDUSTRIAL REVENUE BOND PROGRAM

Loan Application

North Dakota Public Finance Authority
PO Box 5509
Bismarck, ND 58506-5509

1.800.526.3509 or 701.328.7100
Fax 701.328.7130
www.nd.gov/pfa
ndpfa@nd.gov

Industrial Revenue Bond Program

Applicant: 												

Contact Person for Applicant: 									

Title: 							Email:						

Phone: 							Fax:						

Address: 					

All information provided in this program application is certified by the official whose name appears below to be true and correct as of the date on application.

													
Authorized Signature					Date

Printed Name & Title

A.	GENERAL

1.	Applicant’s Fiscal Officer: 										
(if different from above)
	
Email:						

Phone: 							Fax:					

Address: 					

2.	Applicant’s Bond Counsel: 										

3.	Applicant’s Nature of Business: 									

4.	Number of Employees:    Current  		   Proposed  		                          

B.	PROJECT INFORMATION

1.	Description of project to be financed with the bond proceeds:

2.	
Source 	Amount of Funding	
Bond Request 	$	
Bank Financing		
Other Financing		
Equity		
		
Total Project Costs	$	

3.	Number of years to repay loan (maximum term 25 years): __________			

4.	Proposed Closing Date:  		.

5.	If the purpose of the requested financing is to purchase an existing building, please complete the following:

a.	Purchase Price: 			

b.	Amount expected to be expended for improvements:  			

Note:  Must be at least 15% of the amount of the bond issue when purchasing an existing  facility.

C.	OWNERSHIP INFORMATION

Name	
Title	Years of
Experience	Ownership Percentage	

				

D.  OUTSTANDING INDEBTEDNESS

1.  Present Indebtedness:  If necessary, attach additional pages.

 
 Year
Issued	

       Purpose	 

   Type of 
     Debt 	

       Initial
     Amount  	

  Outstanding
      Balance 	
 Avg.Annual   P&I Payment
     Amount	
      Final
   Maturity
      Date	

							

	
2.	Anticipated Indebtedness:  Please list any known future indebtedness of any type, including lease financing, which the Applicant intends to issue or incur in the next twenty-four months.  Include in the description the type of debt, estimated amount and the final maturity. 																 											

3.	Defaults:  If the Applicant has ever defaulted in the payment of principal or interest on any of its outstanding indebtedness, please give a description of the default and any corrective measures taken by the Applicant. 														 																

E.	ATTACHMENTS

1.	Have you completed a Business Plan?  Yes 	 No 	  If yes, please include a copy with the completed application.

2.	The following information must be submitted with this loan application:

•	The three most recent annual audited financial statements.  If you already file audits with the PFA, only provide audits not previously filed.

•	The most recent year-end and month-end balance sheets, income statements and cash flow statements.
 
•	Cash flow projections for the next three years and the current year’s operating budget and the proposed operating budget for the first year of the loan repayment term (and any other years for which a proposed budget has been prepared).

•	The appraisal of collateral for the proposed project.

•	A complete business history.