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---
type: document
title: RLF-Application
file: ../RLF-Application.pdf
tags:
- Cumberland_Plateau_Planning_District_Commission
docDate: null
contentType: application/pdf
contentLength: 1073182
sha256sum: 31bd19b4d59af9114ad8461be47dfd52fe84fda587993732ce3270186c43b069
sha1sum: 142a67b3031c514f30c78bd92c481f45162a359d
---
REVOLVING LOAN FUND
APPLICATION
EDA Title IX Program
CARES ACT RLF
Cumberland Plateau PDC
P.O. Box 548 - 224 Clydesway Drive
Lebanon, VA 24266
REVOLVING LOAN FUND
APPLICATION
EDA Title IX Program
CARES ACT RLF
Cumberland Plateau PDC
P.O. Box 548 - 224 Clydesway Drive
Lebanon, VA 24266
2
CUMBERLAND PLATEAU PLANNING DISTRICT COMMISSION
CARES ACT REVOLVING LOAN FUND PROGRAM
APPLICATION FORM
(Serving the Cumberland Plateau and Lenowisco Planning District Commissions)
Please print or type. Answer all questions or indicate not applicable (NA).
Applications not fully complete shall not be considered.
I. GENERAL INFORMATION
Applicant's Name __________________________ Date
Business Name (if applicable)
Loan Documents in: Applicant’s Name  Business Name
Address
Phone Number
Contact Person Email:
Applicant is: Individual
Partnership
Corporation
 Local Government/Public Entity
CORPORATIONS:
If the applicant is a corporation, officers, directors and principal shareholders,
giving complete name and address for each: (Attached a separate page if needed)
Date of Incorporation State of Incorporation: ___________
For loans to Corporation - Has the Board of Directors approved the loan
application? Yes __ No (REQUIRED --ATTACH
CORPORATE RESOLUTION)
CUMBERLAND PLATEAU PLANNING DISTRICT COMMISSION
CARES ACT REVOLVING LOAN FUND PROGRAM.
APPLICATION FORM.
(Serving the Cumberland Plateau and Lenowisco Planning District Commissions)
Please print or type. Answer all questions or indicate not applicable (NA).
Applications not fully complete shall not be considered.
GENERAL INFORMATION
Applicant's Name Date
Business Name (if applicable)
Loan Documents in: OApplicant’s Name O Business Name
Address
Phone Number
Contact Person Email:
Applicant is: Olndividual
OPartnership
O Corporation
O Local Government/Public Entity
(CORPORATIONS;
If the applicant is a corporation, officers, directors and principal shareholders,
giving complete name and address for each: (Attached a separate page if needed)
Date of Incorporation State of Incorporation:
For loans to Corporation - Has the Board of Directors approved the loan
application? Yes No (REQUIRED --ATTACH
CORPORATE RESOLUTION)
3
If applicant is a corporation, are any individuals willing to guarantee the
loan: (Yes No ).
Individual Name: Title:
Individual Name: Title:
Individual Name: Title:
Individual Name: Title:
Is this a New Venture or an Existing Business
If an existing business, what year was it established
PARTNERSHIPS:
If the applicant is a partnership, give complete name, address and
ownership percentage of each partner: (Personal guarantees are required)
If applicant is a partnership, are any persons other than applicants willing to
guarantee the loan? (Yes NO ).
If yes, give the name and address of each such person.
--For all individual applicants, principals in business, and persons
guaranteeing the loan, please attach current financial statements and
resume
Is this a New Venture or an Existing Business
If an existing business, what year was it established
II. PROJECT DESCRIPTION
Identify the physical location of the proposed project.
County
Town or City _____________________ (if within corporate limits)
I.
If applicant is a corporation, are any individuals willing to guarantee the
loan: (Yes__No __).
Individual Name: Title:
Individual Name: Title:
Individual Name: Title:
Individual Name: Title:
Is this a New Venture or an Existing Business
If an existing business, what year was it established
PARTNERSHIPS;
If the applicant is a partnership, give complete name, address and
ownership percentage of each partner: (Personal guarantees are required)
If applicant is a partnership, are any persons other than applicants willing to
guarantee the loan? (Yes NO_).
Tf yes, give the name and address of each such person.
--For all individual applicants, principals in business, and persons
guaranteeing the loan, please attach current financial statements and
resume
Is this a New Venture ___ or an Existing Business _____
Tf an existing business, what year was it established
PROJECT DESCRIPTION
Identify the physical location of the proposed project.
County
Town or City (if within corporate limits)
4
Is this loan request for Fixed Assets ; Working Capital ___________ ;
or Both If both, % of Working Capital
Has a market study been done addressing the feasibility of the project?
Yes No (If Yes, please attach.)
Generally describe the project, giving purpose of loan. Supply here any
information (not specifically requested in this application) that you feel is
necessary to explain the project. Attach an additional sheet, if necessary.
For an existing business, describe any negative impacts you experienced during
the COVID-19 pandemic. How will CARES ACT RLF funding benefit your
business?
III. COST ELEMENTS OF THE PROJECT
• Site Improvements (Parking, Landscaping) $
• Land Acquisition $
• Purchase and/or Remodel Existing $
Building
• New Construction $
• Machinery and Equipment $
• Architect/Engineering Cost $
• Other Costs (Contingencies) $
• Working Capital $
• TOTAL PROJECT COST $ ____________
These estimates are based on:
Tl.
Is this loan request for Fixed Assets ; Working Capital 3
or Both If both, % of Working Capital
Has a market study been done addressing the feasibility of the project?
Yes No (if Yes, please attach.)
Generally describe the project, giving purpose of loan. Supply here any
information (not specifically requested in this application) that you feel is
necessary to explain the project. Attach an additional sheet, if necessary.
For an existing business, describe any negative impacts you experienced during
the COVID-19 pandemic. How will CARES ACT RLF funding benefit your
business?
COST ELEMENTS OF THE PROJECT
Site Improvements (Parking, Landscaping)
Land Acquisition
Purchase and/or Remodel Existing
Building
New Construction
Machinery and Equipment
Architect/Engineering Cost
Other Costs (Contingencies)
Working Capital
TOTAL PROJECT COST
PAAHAH AAD
These estimates are based on:
5
___ Tentative plans of applicant
___ Preliminary estimates of architect/engineer
____ Detailed plans and specifications done by architect or engineer
___ Other
IV. FINANCING PLAN FOR PROJECT
Sources:
Private
Lender 1
CPPDC
RLF
Other Public
Lender
New Owner’s
Equity
Total**
Amount
Term
Rate
Annual Debt
Service
Collateral Position
** Total Must Equal Total Project Costs (Section III)
(NOTE: The applicant must provide a minimum of 15% equity
1Name and Address of Private Lender
Contact Person
Will any other federal loans or grants be used to finance any part of this
Project? If yes, please specify below agency name and amount:
_____________________________________________________________
V. COMPANY SALES INFORMATION
For Existing Business:
A. Last Year's Sales $
B. This Year's Projected Sales $
C. One Year Projected Sales After
Disbursements of Loan $
For New Businesses:
Tentative plans of applicant
Preliminary estimates of architect/engineer
Detailed plans and specifications done by architect or engineer
Other
Iv. FINANCING PLAN FOR PROJECT
Private CPPDC Other Public | New Owner's
Sources: Lender! RLF Lender Equity Total**
Amount
Term
Rate
Annual Debt
Service
Collateral Position
** Total Must Equal Total Project Costs (Section III)
(NOTE: The applicant must provide a minimum of 15% equity
'Name and Address of Private Lender
Contact Person.
Will any other federal loans or grants be used to finance any part of this
Project? If yes, please specify below agency name and amount:
For Existing Business:
A. Last Year's Sales
B. This Year's Projected Sales
C. One Year Projected Sales After
Disbursements of Loan
For New Businesses:
COMPANY SALES INFORMATION
6
A. One Year Projected Sales After
Disbursements of Loan $
VI. COLLATERAL INFORMATION
Original Present Present liens
Cost Market Value Of Mortgage
Balance, if Any
(1) Land $ $ $
(2) Buildings $ $ $
(3) Business $ $ $
Machinery &
Equipment
(4) Business $ $ $
Furniture &
Fixtures
(5) Accounts $ $ $
Receivable
(6) Inventory $ $ $
(7) Other $ $ $
TOTAL $ $ $
Which of the above collateral is being purchased or constructed as part of the
project? (1. ; 2. . ;3. . ;4. . ;5. . ;6. . ;7. . ;)
Which of the above collateral will be used as security on the RLF Loan?
(1. ; 2. . ;3. ; 4. ; 5. ; 6. ; 7. )
Please attach separate sheets describing the nature, title and value of the
assets offered as collateral for the RLF. Attach a copy of deeds of real
estate.
VII. PROJECTED EMPLOYMENT
When will the project be completed and fully operational?
Month Year
Present Number of Employees
Projected employees six (6) months after loan disbursement
Projected employees twelve (12) months after loan disbursement
‘A. One Year Projected Sales After
Disbursements of Loan 8
VI. COLLATERAL INFORMATION
Original Present Present liens
Cost Market Value Of Mortgage
Balance, if Any
(1) Land $ $ $
(2) Buildings $ $ $
(3) Business $ $ $
Machinery &
Equipment
(4) Business $ $ $
Furniture &
Fixtures
(5) Accounts 8 8 $
Receivable
(6) Inventory $ 8 $
(7) Other $ 8 $
TOTAL $ $ $
Which of the above collateral is being purchased or constructed as part of the
project? (1.32.3...)
Which of the above collateral will be used as security on the RLF Loan?
(32... 4. 35._36._;7._)
Please attach separate sheets describing the nature, title and value of the
assets offered as collateral for the RLF. Attach a copy of deeds of real
estate.
VII. PROJECTED EMPLOYMENT
When will the project be completed and fully operational?
Month Year
Present Number of Employees
Projected employees six (6) months after loan disbursement
Projected employees twelve (12) months after loan disbursement
6
7
Projected employees when project is fully completed and operational
Projected employees to be retained if RLF funds are made available
Has the VA Employment Commission or other job service and training organizations been contacted in
an effort to hire long-term unemployed in the area? Yes No_____
Projected positions to be hired/retained Projected salary/hr. wage
VIII. ADDITIONAL INFORMATION REQUIRED
A. Include copies of the following documents signed by the appropriate
persons: (copies only, please)
1. For existing businesses
a) Latest Balance Sheet and Profit & Loss Statement
(Not older than 30 days)
b) Annual Balance Sheet and Profit & Loss Statements for each
of the last three years
B. If the answers to any of the following questions are yes, please furnish
details in a separate attachment.
1. Have any of the persons listed ever been charged with, or
convicted of, any criminal offense, other than a minor
motor vehicle violation?
 Yes  No
2. Has the Applicant or management of the Applicant been inform
of any current or ongoing investigation of the Applicant with
Projected employees when project is fully completed and operational
Projected employees to be retained if RLF funds are made available
Has the VA Employment Commission or other job service and training organizations been contacted in
an effort to hire long-term unemployed in the area? Yes __ No.
Projected positions to be hired/retained Projected salary/hr. wage
VII. ADDITIONAL INFORMATION REQUIRED
‘A. _ Include copies of the following documents signed by the appropriate
persons: (copies only, please)
1. For existing businesses
a) Latest Balance Sheet and Profit & Loss Statement
(Not older than 30 days)
b) — Annual Balance Sheet and Profit & Loss Statements for each
of the last three years
B. If the answers to any of the following questions are yes, please furnish
details in a separate attachment.
1. Have any of the persons listed ever been charged with, or
convicted of, any criminal offense, other than a minor
motor vehicle violation?
O Yes ONo
2. Has the Applicant or management of the Applicant been inform
of any current or ongoing investigation of the Applicant with
7
8
respect to possible violation of state or federal securities law?
 Yes  No
3. Has the Applicant or any persons listed in items above ever
been in receivership or adjudicated as bankrupt?
 Yes  No
C. Applicants utilizing RLF funds for equipment must provide a
certificate of insurance covering all equipment and fixtures
procured by RLF funds naming the CPPDC as 1st or 2nd loss
payee. Said certificate is to be provided at or before closing and
maintained throughout the life of the loan.
D. Applicants utilizing RLF funds for new construction or adding to pre-
existing structure must provide a certificate of insurance covering
said construction or building naming the CPPDC as 1st or 2nd loss
payee. Said certificate is to be provided at or before closing and
sent to CPPDC each renewal date throughout the life of the loan.
E. Will any portion of this loan be used for new construction,
alteration, or repair work?
 Yes  No If yes, please complete page 10.
IX. CERTIFICATIONS & SUPPLEMENTAL DISCLOSURES
Applicant hereby certifies it is in compliance with federal and state rules and regulations under
Title VI of the Civil Rights Act of 1961. Such certification holds that no person in the United
States shall on the ground of race, color, national origin, sex, handicap, or age be excluded from
participation in, be denied the benefits of, or be otherwise subjected to discrimination under any
program or activity for which Federal financial assistance has been extended. (initial)
The applicant hereby certifies that RLF funds will not be used to relocate jobs from one
commuting area to another. Applicant specifically acknowledges that if RLF funds are
utilized, in any manner, contemporaneous or subsequent to closing, the loan shall be in
default and called. (initial)
Applicant certifies that no portion of RLF funds shall be utilized in lobbying federal, state
or local governments. (initial)
Applicant certifies that all federal, state and local civil rights labor and employment
laws will be followed. (initial)
Applicant certifies that if the project will locate in an area identified as “Flood
Hazard Area” by the Corps of Engineers, FEMA or TV, they will be required to
respect to possible violation of state or federal securities law?
OYes ONo
3. Has the Applicant or any persons listed in items above ever
been in receivership or adjudicated as bankrupt?
O Yes ONo
c. Applicants utilizing RLF funds for equipment must provide a
certificate of insurance covering all equipment and fixtures
procured by RLF funds naming the CPPDC as Ist or 2nd loss
payee. Said certificate is to be provided at or before closing and
maintained throughout the life of the loan.
D. Applicants utilizing RLF funds for new construction or adding to pre-
existing structure must provide a certificate of insurance covering
said construction or building naming the CPPDC as Ist or 2nd loss
payee. Said certificate is to be provided at or before closing and
sent to CPPDC each renewal date throughout the life of the loan.
E. Will any portion of this loan be used for new construction,
alteration, or repair work?
OYes ONo Ifyes, please complete page 10.
IX. CERTIFICATIONS & SUPPLEMENTAL DISCLOSURES
Applicant hereby certifies it is in compliance with federal and state rules and regulations under
Title VI of the Civil Rights Act of 1961. Such certification holds that no person in the United
States shall on the ground of race, color, national origin, sex, handicap, or age be excluded from
participation in, be denied the benefits of, or be otherwise subjected to discrimination under any
program or activity for which Federal financial assistance has been extended. (initial)
The applicant hereby certifies that RLF funds will not be used to relocate jobs from one
commuting area to another. Applicant specifically acknowledges that if RLF funds are
utilized, in any manner, contemporaneous or subsequent to closing, the loan shall be in
default and called. (initial)
Applicant certifies that no portion of RLF funds shall be utilized in lobbying federal, state
or local governments. (initial)
Applicant certifies that all federal, state and local civil rights labor and employment
laws will be followed. (initial)
Applicant certifies that if the project will locate in an area identified as “Flood
Hazard Area” by the Corps of Engineers, FEMA or TV, they will be required to
8
9
obtain Flood Hazard Insurance. (initial)
Applicant certifies that to the greatest extent practicable, they will purchase
American-made equipment and products (initial)
Applicant certifies that they are not listed as debarred, suspended or otherwise
excluded or disqualified from doing business under the Federal Acquisitions
Regulation (initial)
Applicant certifies that no RLF loan proceeds will be used to fund expenses for
which the Applicant has received other federal funding for the same expenses.
_____(initial)
Applicant specifically stipulates that false or fraudulent responses shall constitute
default, when discovered by the Cumberland Plateau Planning District Commission, and
the RLF loan shall be called. Applicant, by its execution hereof, certifies that all information
provided herein is accurate and true.
SIGNATURE
TITLE
DATE
obtain Flood Hazard Insurance. (initial)
Applicant certifies that to the greatest extent practicable, they will purchase
American-made equipment and products (initial)
Applicant certifies that they are not listed as debarred, suspended or otherwise
excluded or disqualified from doing business under the Federal Acquisitions
Regulation (initial)
Applicant certifies that no RLF loan proceeds will be used to fund expenses for
which the Applicant has received other federal funding for the same expenses.
(initial)
Applicant specifically stipulates that false or fraudulent responses shall constitute
default, when discovered by the Cumberland Plateau Planning District Commission, and
the RLF loan shall be called. Applicant, by its execution hereof, certifies that all information
provided herein is accurate and true.
SIGNATURE
TITLE
DATE
10
FOR NEW CONSTRUCTION
PROJECTS ONLY
Applicant certifies that RLF funds will not be used in a manner which will
adversely impact the flood plains, wetlands, significant historic or
archeological properties, drinking water resources, nonrenewable resources,
flora, and wildlife or domestic animals. (initial)
Applicants utilizing RLF funds for new construction and/or substantial building
rehabilitation are required to submit an environmental impact statement from a
licensed environmental engineer which addresses all items set forth.
Applicant certifies that it will follow all federal, state and
local laws and regulations regarding protection and preservation of
the environment. (initial)
DAVIS BACON INFORMATION
Construction financed in whole or in part by the RLF must meet the requirement
of the Davis-Bacon Act as amended. For required hourly wage rates, go to
www.dol.gov.
http://www.dol.gov/
FOR NEW CONSTRUCTION
PROJECTS ONLY
Applicant certifies that RLF funds will not be used in a manner which will
adversely impact the flood plains, wetlands, significant historic or
archeological properties, drinking water resources, nonrenewable resources,
flora, and wildlife or domestic animals. (initial)
Applicants utilizing RLF funds for new construction and/or substantial building
rehabilitation are required to submit an environmental impact statement from a
licensed environmental engineer which addresses all items set forth.
Applicant certifies that it will follow all federal, state and
local laws and regulations regarding protection and preservation of
the environment. (initial)
DAVIS BACON INFORMATION
Construction financed in whole or in part by the RLF must meet the requirement
of the Davis-Bacon Act as amended. For required hourly wage rates, go to
Ww lol.gov.
Applicants Name:
Date:
Business Name if applicable:
Applicants Name_2: Off
Business Name: Off
Address:
undefined:
Phone Number:
Contact Person:
Email:
Individual: Off
Partnership: Off
Corporation: Off
Local GovernmentPublic Entity: Off
giving complete name and address for each Attached a separate page if needed 1:
giving complete name and address for each Attached a separate page if needed 2:
giving complete name and address for each Attached a separate page if needed 3:
Date of Incorporation:
State of Incorporation:
No:
Individual Name:
Title:
Individual Name_2:
Title_2:
Individual Name_3:
Title_3:
Individual Name_4:
Title_4:
Is this a New Venture:
or an Existing Business:
If an existing business what year was it established:
ownership percentage of each partner Personal guarantees are required 1:
ownership percentage of each partner Personal guarantees are required 2:
ownership percentage of each partner Personal guarantees are required 3:
guarantee the loan Yes:
If yes give the name and address of each such person 1:
If yes give the name and address of each such person 2:
Is this a New Venture_2:
or an Existing Business_2:
If an existing business what year was it established_2:
County:
Town or City:
Is this loan request for Fixed Assets:
Working Capital:
If both of Working Capital:
Yes_2:
No_3:
necessary to explain the project Attach an additional sheet if necessary 1:
necessary to explain the project Attach an additional sheet if necessary 2:
necessary to explain the project Attach an additional sheet if necessary 3:
necessary to explain the project Attach an additional sheet if necessary 4:
business 1:
business 2:
business 3:
business 4:
undefined_2:
undefined_3:
undefined_5:
undefined_6:
undefined_7:
undefined_8:
undefined_9:
undefined_10:
Private Lender 1Amount:
CPPDC RLFAmount:
Other Public LenderAmount:
New Owners EquityAmount:
TotalAmount:
Private Lender 1Term:
CPPDC RLFTerm:
Other Public LenderTerm:
New Owners EquityTerm:
TotalTerm:
Private Lender 1Rate:
CPPDC RLFRate:
Other Public LenderRate:
New Owners EquityRate:
TotalRate:
Private Lender 1Annual Debt Service:
CPPDC RLFAnnual Debt Service:
Other Public LenderAnnual Debt Service:
New Owners EquityAnnual Debt Service:
TotalAnnual Debt Service:
Private Lender 1Collateral Position:
CPPDC RLFCollateral Position:
Other Public LenderCollateral Position:
New Owners EquityCollateral Position:
TotalCollateral Position:
1Name and Address of Private Lender 1:
1Name and Address of Private Lender 2:
Contact Person_2:
Project:
undefined_11:
undefined_12:
undefined_13:
undefined_14:
undefined_15:
undefined_16:
undefined_17:
undefined_18:
undefined_19:
undefined_20:
undefined_21:
undefined_22:
undefined_23:
undefined_24:
undefined_25:
undefined_26:
undefined_27:
undefined_28:
undefined_29:
undefined_30:
undefined_31:
undefined_32:
undefined_33:
undefined_34:
undefined_35:
undefined_36:
undefined_37:
undefined_38:
project 1:
Month:
Year:
Present Number of Employees:
Projected employees six 6 months after loan disbursement:
Projected employees twelve 12 months after loan disbursement:
undefined_39:
Projected employees when project is fully completed and operational:
Has the VAEmployment Commission or other job service and training organizations been contacted in:
No_4:
Projected positions to be hiredretained 1:
Projected positions to be hiredretained 2:
Projected positions to be hiredretained 3:
Projected positions to be hiredretained 4:
Projected salaryhr wage 1:
Projected salaryhr wage 2:
Projected salaryhr wage 3:
Projected salaryhr wage 4:
VIII ADDITIONAL INFORMATION REQUIRED:
motor vehicle violation: Off
respect to possible violation of state or federal securities law: Off
been in receivership or adjudicated as bankrupt: Off
alteration or repair work: Off
initial:
initial_2:
initial_3:
initial_4:
initial_5:
Applicant certifies that to the greatest extent practicable they will purchase:
archeological properties drinking water resources nonrenewable resources:
local laws and regulations regarding protection and preservation of:
undefined_4:
1:
3_2:
4_2:
5_2:
6_2:
7_2:
2:
Other:
provided herein is accurate and true:
TITLE:
excluded or disqualified from doing business under the Federal Acquisitions:
No_2:
Yes:
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