Agent Name

Phone

Fax

Date

Email Address

Business Information: Type of Business

Years in business?

Is operation a Franchise? Is operation a Franchise? Yes No

Is the note personally guaranteed? Is the note personally guaranteed? Yes No

Business location leased? Business location leased? Yes No

Business Name

Street Address of Business

City/State

Sell Price of Business

Downpayment

Original Note Balance

Months Financed

Interest Rate on Note

Date of First Payment

Monthly Payment Amount

Number of Payments Remaining

Balloon Payment Balloon Payment Yes No

Current Balance of Note

Credit of Payer Credit of Payer Excellent Good Poor Unknown

New Field New Field I agree to Terms and Conditions provided by the company (see below). By providing my phone number, I agree to receive text messages from the business.