First Name:  *

Last Name:  *

Your Time Zone:  *

Best Time To Call You Back w/ Quote:  *

(Area Code) Phone Number:  *

Email Address:  *

Your Address:  *

Your City:  *

State: Select One:AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington D.C.West VirginiaWisconsinWyoming

Zip Code:  *

Business Information:

Name of Business  *

Type of Business:  *

Street Address:  *

City:  *

State: Select One:AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington D.C.West VirginiaWisconsinWyoming

Zip:  *

County:  *

Is operation a franchise: NoYes

If yes. has franchisor committed to cooperate with seller in the event of foreclosure/resale: YesNo

How long in business at this location:  *

Business Location is: Owned by PayorLeased by Payor

If leased when does lease expire:

Give terms of any lease renewal option(s):

Qualifications of Payor to operate this business:  *

Is payor a corporation: NoYes

If Payor is a Corporation does the note carry a Personal Guaranty of the Payor? YesNo

Payors Name:  *

Payors Address City State Zip:  *

Payors Social Security Number:

Payors Credit is Believed to be: A - ExcellentB - GoodC - Below AverageD - Poor

Note payors credit score (if available):

Description of business location & area:  *

Receivable Information:

Date of Sale:  *

Sales Price:  *

Down Payment:  *

1st Lien Amount:  *

Date 1st Payment was Due:  *

Next Payment Due Date:  *

Term of Note (in months):  *

Balloon Date (if any):

Balloon Amount (if any):

Current Balance 1st Lien:  *

Interest Rate:  *

Payment Amount 1st Lien:  *

Number of Payments Made:  *

Number of Payments Remaining:  *

Additional Information:

Equipment $:

Inventory $:

Goodwill $:

Non-Compete Agreement $:

Real Estate $:

Reason for Selling Note:  *

Do you have and can you supply copies of the following:

Note: No Yes

Security Instrument: NoYes

Title: NoYes

Sales Contract: NoYes

Payors Credit Report: NoYes

Closing Statement: NoYes

Bill of sale: NoYes

Insurance: NoYes

Lease: NoYes

Franchise Agreement: NoYes

UCC Filing: NoYes

Payment History: NoYes

What type of purchase are you interested in? Full Purchase Partial Purchase

Is there a specific dollar amount you need to raise?  *

What is your relationship to this transaction: Note Holder/SellerNote Broker/Note FinderMortgage Broker/Loan OfficerRealtor/AgentAttorney/CPA/Fin. PlannerEstate RepresentativeFamily/Friend

I am ready for a free quote and if your offer meets my approval I am ready to close the transaction within the next 30 days: YesNo

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