City of Fontana’s Empowerment Revolving Loan Fund Program Administered by AmPac Tri-State CDC, Inc. dba AmPac Business Capital Disbursement Request and Authorization
[Borrower’s Legal Name]- [Loan Product] Loan #[Loan Number] Disbursement Request and Authorization Page 1 of 1
LOAN TYPE: [Loan Product]. This is a Fixed Rate Loan for [Loan Amount ($0.00)] , due on [Maturity Date].
PRIMARY PURPOSE OF LOAN: [Primary Use of Funds]. The primary purpose of this Loan is for [Primary Use of Funds].
DISBURSEMENT INSTRUCTIONS: Borrower understands that no Loan proceeds will be disbursed until all of Lender’s conditions for making the Loan have been satisfied. Please disburse the Loan proceeds as follows: [Special Disbursement Instructions, If Applicable].
Other Disbursements: [Total of Disbursements]
[Disbursement(s)] [($0.00]
Total Financed/Prepaid Charges: [Total Fees]
Loan Packaging and Processing: [($0.00]
Legal Fees: $350.00
Out of Pocket and Interest to
Month End: [($0.00]
Note Principal Amount: [Total Principal Amount]
FINANCIAL CONDITION: BY SIGNING THIS AUTHORIZATION, BORROWER REPRESENTS
AND WARRANTS TO LENDER THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND
CORRECT AND THAT THERE HAS BEEN NO MATERIAL ADVERSE CHANGE IN BORROWER’S FINANCIAL CONDITION DISCLOSED IN BORROWER’S MOST RECENT FINANCIAL STATEMENT TO LENDER.
THIS DISBURSEMENT REQUEST AND AUTHORTIZATION IS DATED: [DATE].
Borrower:
[Borrower’s Legal Name]
______________________________________
[Signer(s) Legal Name(s), and Title(s)]