Referral Form SOUTH CAROLINA COMMUNITY CAPITAL ALLIANCE LOAN REFERRAL FORM All information provided herein is deemed confidential and will not be shared 1. REFERRING ORGANIZATION Organization Name: (if applicable) Contact Name and Title: Street Address: City: State: Zip Code: County: Telephone Number: Fax Number: Email Address: 2. BORROWER INFORMATION Organization Name: (if applicable) Contact Name and Title: Street Address: City: State: Zip Code: County: Telephone Number: Fax Number: Email Address: 3. BORROWER TYPE Non-ProfitFor ProfitGovernment EntityJoint VentureIndividualOther Other: 4. BUSINESS OR PROJECT INFORMATION (Please include address where your business or project is or will be located, if applicable) Name: (if applicable) Street Address: City: State: Zip Code: County: Description: 5. LOAN INFORMATION Loan Amount Needed: Description of Use of Proceeds: Description of Collateral: (if applicable) 6. LOAN TYPE Affordable HousingHealthy FoodCommunity FacilitySmall BusinessMicro-LoanConsumer 7. LOAN PURPOSE (Select All That Apply) AcquisitionPre-DevelopmentInfrastructureConstructionRehabilitationLeasehold ImprovementsMachinery and EquipmentWorking CapitalPermanent FinancingRefinancePersonalOther Other: 8. LOAN TERM NEEDED 9. LOAN IMPACTS Located in Low to Moderate Income Census Tract? YesNo Located in USDA Designated Food Desert? YesNo Located in USDA Designated Rural Community? YesNo Will Employ Low to Moderate Income Individuals? YesNo Will SERVE or HOUSE Low to Moderate Income Individuals? YesNo Estimated Number of JOBS to be Created/Retained: Estimated Number of UNITS to be Created/Rehabilitated: 30% AMI 50% AMI 80% AMI 120% AMI 10. ADDITIONAL INFORMATION Description: Δ
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