Finance Request Details

Applicant or Company Information

Company or Individual's Name

Phone and/or Cell Number

Fax Number

Contact Name (if Company)

Contact Phone (if Company)

Date of Birth (if individual)

Federal ID or SSN

Business Structure

Street Address

City

State

ZIP Code

State Incorporated

State Org ID

Date Established / Time In Business

Major Ag Product

Number of Acres Farmed

Total Assets

Total Liabilities

Gross Annual Farm Revenue

Annual Non-Farm Income

Equipment Insurance Company

Agent Name

Agent Phone Number

Agent Fax Number

Co-Applicant, Owner, Partners or Guarantor Information

Co-Applicant Name

Co-Applicant Address

Co-Applicant SSN

Title /% Ownership

Date of Birth

Co-Applicant Name

Co-Applicant Address

Co-Applicant SSN

Title /% Ownership

Date of Birth

Equipment Information

Equipment Make

Equipment Model

Equipment Year

Equipment Condition

Equipment Cost

Amount Requested

Dealer Name

Dealer Location

Dealer Contact

Dealer Phone

Amount Owed on Equipment

Is Equipment Being Traded?

Will Equipment Be Used for Custom Work?

Finance Request Type

Finance Term

Payment Type