Angola Investment Fund

Angola Investment Fund Confidential Application Form

Information contained herein is limited to review by Angola Investment Fund Board Account and Partners Not Subject to Public Disclosure.

Submit application and accompanying documents to Isaac Lee, SCEDC Executive Director, [email protected] or Kathy Armstrong, Angola Common Council, [email protected] Call 260-665-6889 for more information. APPLICANT & PROJECT SUMMARY 1. Name of Applicant 2. Contact Person

3. Mailing Address 4. Physical Address (if different)

5. Contact Telephone 6. Contact E-mail

7. Business Name (if different from applicant) 8. Principal Owner(s)

9. Business Description – Product / Service (Attach additional pages if necessary)

10. Brief Business History (Attach additional pages if necessary)

11. Amount of Request 12. Total Project Costs $ $ 13. Project Description (Attach additional pages if necessary)

Itemized Use of Funds: a. Salaries & Wages ______b. Raw Materials ______c. Equipment Purchase ______d. Real Estate Purchase ______e. Shipping – Transportation Costs ______f. Training Expenses ______g. Other (Describe): ______h. Other (Describe): ______

14. Describe Other Funding Sources and Approval Status

ECONOMIC IMPACT 15. Number of Existing Jobs: 16. Estimated Number & Avg. Wages of new Jobs:

Average Hourly Wage of Existing Jobs: # Avg. Hourly Wage $ One Year $

Three Years $ 17. Please describe any new or advanced technologies used by the applicant:

18. Please describe local economic impact proposed by the applicant:

Required Attachments:

a. Prior Three Year Profit & Loss Statements and Balance Sheets b. Business Plan with Three Year Financial Pro Forma / Projections c. Personal Financial Statements of Owners / Principals d. Proof of Funding Commitments from Other Funding Sources and/or Equity Sources e. Resumes of Owners, Principals and/or Key Management Personnel

Authorization:

Applicant hereby agrees that the Angola Investment Fund (AIF) and/or a contractor for the AIF is authorized to access credit reports for any and all companies identified in this applicant, and for any and all individuals identified in this application. The AIF reports that it and/or a contractor of the AIF may access such credit reports from Experian or other reputable source.

Applicant hereby agrees that the Angola Investment Fund (AIF and/or contractor for the AIF is authorized to access criminal background reports for any and all individuals identified in this application.

The signature below acknowledges that the applicant has read and is aware of the AIF’s intent to access credit reports and criminal background reports as described.

Signature of Applicant: Title:

Name: Date: