Application | Golden Financial Solutions

GENERAL INFORMATION

Company Legal Name *

Primary Physical Address

Mailing Address (if different than above)

Phone

Fax

Federal Tax ID Number

Company Inception (mo/year)

State of Incorporation

Primary treatment provided

Primary transaction type

Does the Company currently operate under any other names? (If yes, please list)

Has the Company operated under any other names in the past? (If yes, please list)

Number of Locations

Contact Person Name *

Contact Person Title *

Contact Person Phone

Contact Person Email *

LIST OF PRINCIPALS / SHAREHOLDERS IN COMPANY

Principal/Shareholder

Primary Physical Address

Social Security No.

Date of Birth

Principal/Shareholder II (if applicable)

Primary Physical Address

Social Security No.

Date of Birth

Principal/Shareholder III (if applicable)

Primary Physical Address

Social Security No.

Date of Birth

Principal/Shareholder IV (if applicable)

Primary Physical Address

Social Security No.

Date of Birth

Principal/Shareholder V (if applicable)

Primary Physical Address

Social Security No.

Date of Birth

OPPORTUNITY INFORMATION

Provide brief overview of the Company’s history

Please explain why you are seeking financing for your receivables

Please describe the ideal outcome of this transaction for you

What % of your business is workers’ compensation? PI? Other?

Please describe the types of treatment or services you offer

Approximately how much gross are you currently billing per month?

Approximately how much are you collecting per month?

How much total gross in receivables are currently outstanding?

Estimated value of total outstanding book

Are you interested in an ongoing/monthly funding relationship?

yes

Are you currently being financed by any other company? If so, describe the terms

SERVICING REVIEW

Name of Collection Company(s)

Is the collection company(s) aware that you are selling your receivables?

Is There a Termination Fee if we Decide to Move the A/R to another Collection Company? (If yes, how much?)

What is the Current Process for Collecting on Your Receivables?

How Often Are the Cases Being Status Checked to Confirm the Validity?

Are There Any Encumbrances or UCCs on the Receivables? (if yes, please explain)

LEGAL REVIEW HAS THE COMPANY OR ANY OF ITS PRINCIPALS:

Been the Subject of Any Bankruptcy Proceedings (If yes, please explain)

Been Questioned or Investigated by Any Law Enforcement Agencies (if yes, please explain)

Is the Company or Any of its Principals Defendants in any Lawsuits? (if yes, please explain)

Are There Any Claims, Actions, Suits, or Judgements Pending Against the Company? (if yes, please explain)

Medical Accounts Receivable Application

GENERAL INFORMATION

LIST OF PRINCIPALS / SHAREHOLDERS IN COMPANY

OPPORTUNITY INFORMATION

SERVICING REVIEW

LEGAL REVIEW HAS THE COMPANY OR ANY OF ITS PRINCIPALS: