"Application for Financial Assistance Loans and Loan Guarantees" - New Brunswick, Canada

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APPLICATION FOR FINANCIAL ASSISTANCE
LOANS AND LOAN GUARANTEES
Department of Agriculture, Aquaculture & Fisheries
Industry Financial Programs
PO Box 6000
Fredericton, NB E3B 5H1
(506) 453-2666
NOTE: Applications will not be processed until all required information is received. You may be
requested to provide additional information. If requested information is not received
within 30 days of request, your application will not be processed any further and it will
be returned to you.
A.
APPLICANT INFORMATION
Name of company or person applying: ______________________________________________
Postal address: ________________________________________________________________
Phone:
_____________________
Cell:
________________________
E-Mail:
_________________________________
Physical address of business: _____________________________________________________
Contact Person and Title: ______________________________
Social Insurance Number: _______________
Date of Birth:
_________________
B.
ASSISTANCE REQUESTED
1.
Amount requested:
$
Term:
years
2.
Please indicate the program(s) you are applying for:
_____ Agriculture Loan
_____ Agriculture Loan Guarantee
_____ Livestock Incentive Loan
_____ Fisheries Loan
_____ Fisheries Loan Guarantee
_____ Aquaculture Loan
_____ Aquaculture Loan Guarantee
3.
Describe the purpose of the financial assistance being applied for, how it will be used,
and when it is required:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
APPLICATION FOR FINANCIAL ASSISTANCE
LOANS AND LOAN GUARANTEES
Department of Agriculture, Aquaculture & Fisheries
Industry Financial Programs
PO Box 6000
Fredericton, NB E3B 5H1
(506) 453-2666
NOTE: Applications will not be processed until all required information is received. You may be
requested to provide additional information. If requested information is not received
within 30 days of request, your application will not be processed any further and it will
be returned to you.
A.
APPLICANT INFORMATION
Name of company or person applying: ______________________________________________
Postal address: ________________________________________________________________
Phone:
_____________________
Cell:
________________________
E-Mail:
_________________________________
Physical address of business: _____________________________________________________
Contact Person and Title: ______________________________
Social Insurance Number: _______________
Date of Birth:
_________________
B.
ASSISTANCE REQUESTED
1.
Amount requested:
$
Term:
years
2.
Please indicate the program(s) you are applying for:
_____ Agriculture Loan
_____ Agriculture Loan Guarantee
_____ Livestock Incentive Loan
_____ Fisheries Loan
_____ Fisheries Loan Guarantee
_____ Aquaculture Loan
_____ Aquaculture Loan Guarantee
3.
Describe the purpose of the financial assistance being applied for, how it will be used,
and when it is required:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
2
4.
Provide the sources and use of all funds to be expended over entire course of proposed
project:
Source
Amount
I
Use
Amount
____________
__________
I
____________
__________
____________
__________
I
____________
__________
____________
__________
I
____________
__________
____________
__________
I
____________
__________
Total
__________
I
Total
__________
5.
Number of jobs to be created: _____
Number of jobs to be maintained: ______
C.
COMPANY INFORMATION
1.
Legal form of business:
_____ sole proprietorship
_____ partnership
_____ incorporated company
to be incorporated
_____ cooperative
2.
Attach the following (if incorporated):
a)
current list of shareholders (names, addresses, ownership of each class of
shares)
b)
current list of directors (names, addresses)
c)
current list of officers (names, management position, years with business)
3.
Business advisors (names and telephone numbers):
a)
banker / lender:
b)
accountant:
c)
lawyer:
D.
BUSINESS PLAN INFORMATION
Attach a business plan that includes the following information:
description of business and proposed project;
financial information:
previous 3 years financial statements or income tax returns (if existing
operation);
3-year annual projected income statements and balance sheets;
3-year monthly projected cash flow statements;
description of management plan (how business will be operated) and
management’s qualifications including education and work experience;
marketing plan (to whom and how products will be sold); and
production details (3-year historical summary of actual production and 3-year
summary of projected production, including assumptions).
3
E.
PERSONAL BALANCE SHEET (to be completed where applicant is an individual and
not a business)
Date: ___________________ 20 _____
Name: ____________________________
Assets
$____________________
Bank Account Balances
Investments (Stocks, Bonds, RRSPs)
____________________
Motor Vehicles (make, model & year):
_____________________
____________________
_____________________
____________________
Residence (Tax Assessment Value)
____________________
Land (Estimated Value)
____________________
Other Assets ______________________
____________________
Other Assets ______________________
____________________
Other Assets ______________________
____________________
TOTAL ASSETS
$____________________
Liabilities
Loan(s): Lender
Payments
__________
__________
$_____________________
Credit Card Balances
_____________________
Account Payables
_____________________
Provincial Loan(s)
_____________________
Mortgages
_____________________
Income Tax Owing
_____________________
Other Liabilities _____________________
_____________________
Other Liabilities _____________________
_____________________
Other Liabilities _____________________
_____________________
TOTAL LIABILITIES
$_____________________
Net Worth:
$_____________________
Please provide your annual income and sources of that income:
Total household income last year (all sources)
$_____________________
Source: _____________________ $ _______________
Source: _____________________ $ _______________
4
G.
LEGAL DECLARATION
Describe all outstanding or pending legal actions against the applicant. If none, state “Not
Applicable”.
_____________________________________________________________________________
_____________________________________________________________________________
H.
AUTHORIZATION
The undersigned certifies that the information and representations contained in this application
form are true and correct to the best of his/her knowledge and belief. If the applicant is a
business, then the undersigned also certifies that he/she has authority to make this application on
behalf of the business.
The undersigned gives consent for the Minister of the Department of Agriculture, Aquaculture
and Fisheries of the Province of New Brunswick, and for the employees, agents, successors and
assigns of the Minister, to seek and obtain further and other information to whatever extent and
from whatever sources or records, and to discuss this application and the business and affairs of
the applicant with the applicant’s bankers/lenders, accountants, lawyers, and anyone else, as the
Minister, or employees, agents, successor and assigns of the Minister deems necessary or
considers appropriate for the purposes of this application.
Depending on the type of financial assistance being requested, the personal information
collected on or pursuant to this application form is collected either under the authority of the
Agricultural Development Act, SNB 2014, c. 55, s. 13, or under the authority of the Fisheries
and Aquaculture Development Act, SNB 2009, c. F-15.001, s. 5, and will be used to determine
eligibility for the requested financial assistance. Also, if necessary, personal and financial
information collected on or pursuant to this application form will be used for the purposes of
debt collection, and disclosed to third parties for that purpose.
Questions about this application form, as well as questions about the collection, use and
disclosure of personal information hereunder, can be directed to Industry Financial Programs
Branch of the Department of Agriculture, Aquaculture and Fisheries, in person or by mail at
1350 Regent Street, PO Box 6000, Fredericton, NB, E3B 5H1, or by phone at (506) 453-2666.
Signed this
day of
, 20_____
Print name of applicant: ___________________________
Signature: __________________________________
(Date of last revisions to application form: May 2019)
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