Collateral Assistance Program

Borrower Personal Information

Legal Company Name

Contact First Name

Contact Last Name

Contact Title

Email Address

Phone Number

Company Address

City

State

Zip

Potential Economic Impact Information

Current # of full-time employees

Current # of part-time employees

# of full-time jobs to be created within 2 years

# of part-time jobs to be created within 2 years

Average hourly wage for full-time employees

Average hourly wage for part-time employees

Note: Full-time is more then 2,000 hours per year; part-time is less then 2,000 hours per year; created or retained jobs must be within New Mexico.

What is the total amount of private investment in this project (excluding loan amount)

Other projected benefits to New Mexico

Loan and Lender Information

Lending Institution Name

Branch Location

Lender First and Last Name

Lender Phone Number

Lender Email Address

Loan Number

Expected Initial Disbursement Date

Loan Type

Line of CreditTerm LoanOther

Other

Total Project Cost

Loan Amount

Amount of equity contributed by borrower

Length of loan or line of credit (in months)

Length of amortization (in months)

Interest rate

Numbers only

Debt coverage ratio

Project Sources and Uses

Please itemize the borrower's use of loan proceeds (include dollar amount and source) For example, "Building, $25,000, Private Investment"

Please describe the project

Project proposed start date

Describe the borrower's collateral (include Estimated Value $, Lender's LTV %, and Lender Credit $) For example, "$75,000, 45%, $15,000"

Total collateral amount recognized by Lender ($)

What is the gap in collateral? ($)

What is the requested collateral amount from the NM CAP?

What is the requested time frame for the CD?

Why does the collateral shortfall exist?

Please explain why the lending institution is unable to make the loan without the CAP financial support?

Refinance Information

Will this loan or line of credit include a refinance of existing debt with the same financial institution?

YesNo

Will this loan or line of credit include a refinance of existing debt with a different financial institution?

YesNo

If yes, what is the amount of debt being refinanced?

Supplemental Documents

Accompanying this application please provide the following supplemental documents on the project: 1. Lending institution's Credit Memo/Analysis 2. Business financial statements (PL, Cash Flow and Balance Sheet) for the past three years including an interim statement dated within 90 days of application *Personal tax-returns from the owner/s may be requested in lieu of financial statements for start-ups. 3. Business plan 4. Financial projections for the project up to the next 3 years. 5. Please provide any additional material which would help prove the viability of the project to the CAP Review Board. (Please combine any additional info into a single PDF or email each separately to the address below) Please upload below. Please send questions to edd-finance@state.nm.us.

1. Lending institution Credit Memo/Analysis

2. Business Financial Statements

3. Business Plan

4. Financial Projections

5. Additional Documents

File access instructions, if needed:

Affirmation

The checkbox and fields below affirms that the borrower certifies that the information in this Loan Enrollment Form and Eligibility Questionnaire is true and accurate to the best of their knowledge and belief.

A copy of this application will be sent to the Lender entered on this form.

Borrowers Authorization

I certify that the information in this form is true and accurate to the best of my knowledge

Borrowers Name and Title