Capital Invoice, LLC - Factoring Application

General Information

Exact Business Name: *

DBA(if applicaple):

Website Address:

Email: *

Street Address, City, State, zip *

Phone # *

Mailing Address (if different):

Federal Tax I.D.: *

State Filed In: *

MC # (if Applicable)

US DOT # (if Applicable)

Type of enitity: *

Corporation

LLC

Sole Proprietor

Partnership

Year Established for specific entity: *

End of Fiscal Year: *

Number of Employees: *

How are your employees paid?

How did you hear about Capital Invoice, LLC? *

Shareholder Information

Principal 1

Name: *

Title: *

% Owned: *

Home Street Address, City, State, Zip *

Own or Rent: *

Own

Rent

Date of Birth: *

Social Security #: *

Principal 2

Name:

Title:

% Owned:

Home Street Address, City, State, Zip

Own or Rent:

Own

Rent

Date of Birth:

Social Security #:

Operational Information

Estimated Annual Sales *

Amount to Factor Monthly *

Average Invoice Amount *

1. Do you now or have you in the past had a Factoring Relationship? *

Yes

N0

What company?

When?

2. Have any of the principals ever been convicted of a felony? *

Yes

No

3. Has the company ever declared bankruptcy? Have any of the principals declared personal bankruptcy? *

Yes

No

What Year?

What Chapter?

4. Are there any unsatisfied judgements or liens against the company or its principals? *

Yes

No

5. Does the company have any outstanding loans or lines of credit? *

Yes

No

Please provide information about the amount, the secured party, and collateral.

6. Are you current on any and all Federal, State, or withholding taxes? *

Yes

No

Do you currently have a payment plan? Please provide documentation and proof of payment when sending in your application

Yes

No

7. Do any of the principals own any other businesses? *

Yes

No

Please provide Exact Business Name, Address, DBA (if applicable), type of business, Federal Tax ID, state file in, year filed, and website.

8. Has your business been under any other name in the last five years? *

Yes

No

Please provide previous name and reason for changing.

9. Does your business require any specific licenses of permits to operate? *

Yes

No

Please email your documentation to show your licenses as current to apply@capitalinvoice.com after submitting your application.

10. Do you anticipate any major changes in ownership or management within the next 12 months? *

Yes

No

11. How do you send your invoices to your customers? *

Please list the clients you wish to fund below (or send in a separate client list).

Business Name, Headquarters Address, and Headquarters Phone

I affirm that all the information provided within this application is true and accurate. I Authorize Capital Invoice (as deemed necessary) to verify the accuracy of the statements and information provided and to conduct a credit investigation and background check. I further agree that any adverse material change to the financial condition previously supplied must be reported within (15) days.

Signature (Principal 1) and Date *

clear

Signature (Principal 2) and Date

clear

To expedite the approval process, please complete/attach the items below and email to Caleb@capitalinvoice.com.

1. Copy of Driver's License for each principal

2. Previous 6 months' bank statements

3. Previous 2 years' tax returns for business (if business is newer than 2 years, please provide 2 years' personal tax returns)

4. Accounts Receiveable and Accounts Payable Report - Most Recent

5. Copy of invoices you wish to factor and any supporting documentation (work orders, proof of payment for past invoices)

6. Copy of service contacts (if applicaple)

7. Copy of Organizational Docs: Articles of Organization, Incorporation Articles, or Partnership Agreement

8. Copy of DBA Filing (if applicaple)

9. Full customer list with Address and contact information