Contact Information

Your Name 	
Date 		
Phone 		
FAX 		
  

Business Information

Type of Business 

Asset Value Breakdown:
	Equipment ($) 
	Inventory ($) 
	Goodwill  ($) 

Is operation a Franchise?  Yes  No

If yes, has franchisor committed to cooperate with note buyer 

in event of foreclosure/resale?   No  Yes

Street Address (if available):
	

How long in business at this location? 
Business location is

 Owned by Payor  Leased by Payor 
If LEASED, 
Expires: 

  
Terms of any lease renewal option(s):

  
What qualifications does the payor have to operate this business?

  
If payor is a corporation, is there also a creditworthy individual 

liable for payments?  Yes  No
If so, name: 
  
Historical Information

Date of Sale 	
Selling Price 	
Down Payment 	
1st Lien 		
2nd Lien 		
  

Note Information

Date of Note 	
Amount	($) 	
Term in months 	
Payment Amount	
Balloon Amount 	
Balloon Date	
Interest Rate 	
Due Date 1st PMT 	
# of payments paid	
# of payments left	
Next Payment due	
Balance 		
  

Description of Business Location & Area

Payor Information

Please provide as much information as you can about the person making payments to you (Employment Info, Payment Record, Payor S.S.#, etc.)

Motivation Information

Please explain why you need to sell the debt instrument, how much you expect for it, and how soon you need to close.

Pertinent Documents

Do I have the following:
Yes No - Note
Yes No - Security Instrument
Yes No - Title
Yes No - Sales Contract
Yes No - Payor credit report
Yes No - Closing Statement
Yes No - Bill of sale
Yes No - Insurance
Yes No - Lease
Yes No - Franchise agreement
Yes No - UCC-1