E-Community Check Request Checklist The E-Community must complete the following information on each business approved for a loan or grant in order for the Kansas Center of Entrepreneurship (KCFE) to disburse a check: Business loan/grant application. See attached sample A of the required application questions. Minutes of the meeting where the business was approved as part of the E-Community s process. Scoring system used for approval by the committee as part of the E-Community s process. Verification of financial commitments from private and public capital funding organizations. For example, letter from a financial institution indicating approval of a loan, or copies of checks. Note: The matching partner must have closed on their loan prior to requesting a check from KCFE. Check request form completed and signed (attached sample B). Please do not use the sample, use the version of the form available on the resource partners only section of our website. Initial report completed and signed (attached sample C). Please do not use the sample, use the version of the form available on the resource partners only section of our website. Signed copy of the Loan Agreement and Promissory Note between the Business and Provider and Matching Partner documents. See attached sample D and E. An amortization schedule for each set of terms; monthly payments indicating portion applied to principle and interest and any administrative fees withheld. See attached sample F. Note: Sample G is a follow-up report that will be conducted by the Center for Entrepreneurship. Please ensure the business receiving the funds is aware of this report. A description is provided on the form. Please send all documents to the following address: Kansas Center for Entrepreneurship dba NetWork Kansas Attention: Jamie Hofling 1845 North Fairmount Campus Box 202 Wichita, KS 67260-0202 If you have any questions regarding the list or would like to confirm that all documents are accurate prior to sending them, please contact Jamie Hofling, Product Manager of Economics at 316-978-7317 or via email at jkhofling@networkkansas.com. Upon receipt and verification of all the above items, please allow 3-5 business days to disburse a check. 1
E-Community Application Applicant Information 1. Name 2. Name of business a. If company, list entity type (LLC, sole proprietorship, etc.) 3. Mailing Address 4. Phone Number 5. Fax Number 6. Email Address 7. See business plan. 8. Will the business be located at the same address as listed in Question 3? 9. Does the entrepreneur or small business owner have a tax liability in arrears with the Kansas Department of Revenue or IRS? Requested Funding Information 10. How much funding are you requesting from E-Community for this project? 11. Date needed: 12. Funds are for a business startup. 13. 14. List any additional funding and the amount that will be utilized in this project 15. Please describe the project in detail and provide a breakdown of how it's expected the funds will be used for this project see business plan 16. Please provide projected sales, sales growth and any projected job creation/employment growth from this project (both full and part-time). see business plan 17. What will be the benefit to the community from this project? 18. Are there any other comments we need to know about why you need this funding and how it will benefit the county and community? 19. Please read the Marketing Release of Information Declaration and place an x if you understand and agree to the terms described. Agree Signed copy is attached. 2
Check Request Form E-Community Administrator for E-Community Organization name: Address: City, state, zip: County: Make check payable to: Check Amount Requested: $ If applicable, administration fee per month $ E-Community Matching Partner Organization name: Address: City, state, zip: County: Percent of Partner Match: Dollar Amount of Match: Provide the terms between the Client and the Provider; interest rate and length of the loan: Signature of Authorized Person: Printed Name and title: 3
Sample C Initial Report The Provider will supply an initial report to the Kansas Center of Entrepreneurship to track the success of services provided to Kansas Entrepreneurs and small businesses. COMPANY INFORMATION Company name: Address: City, state, zip, county: Email: Entity type: Business type: startup, expansion, business purchase or retention of a current business: COMPANY DEMOGRAPHICS NAICS code or type of business: Month/Year business established: Owner s status prior to starting business: Owner s gender: Owner s race: City population-business location (less than 1,000, 1-5K, 5-10K, 10-25K): SNAPSHOT OF COMPANY AT TIME OF FUND AWARD Does the business file tax return on a calendar or fiscal year basis? If a fiscal year basis is used, what is the business fiscal year end? Full-time employees (headcount, including owners working full time in the business): Part-time employees (headcount and hours worked week): Business stage (pre-venture, start-up, expansion, or purchase of existing business): Annual revenue: Annual net income/(loss): If applicable, Full-time jobs to be created as result of fund award & average salary of job: If applicable, Part-time jobs to be created as result of fund award & average wage of job: If applicable, Full-time jobs saved as a result of fund award & average salary of job: If applicable, Part-time jobs saved as a result of fund award & average wage of job: LEVERAGED CAPITAL (for this instance, not historically) If E-community funds were a loan, what was the amount of business down payment: If E-community funds were a grant, what was the amount of business investment: Private capital loaned: (bank loans, other private investor not including the business owner) Private capital invested (equity position): (private investors who have loaned money in return for equity/ownership in the company) NetWork Kansas Resource Partner loan: (loan amount provided by the matching partner) NetWork Kansas Resource Partner grant: (grant amount provided by the matching partner) Additional Public Capital loaned or granted, please explain: (any public capital that isn't listed above, including Certified Development Companies, Regional Foundations, USDA, city/county microloans or revolving loan funds). If purchase of existing business, please list owner carry amount: Signature of Authorized Person: Printed Name and title: 4
Sample F Amortization Schedule Name of Business: Loan origination date: Loan: First payment: Rate: Maturity: Term: Date Payment Payment Beginning Monthly Ending Received # Balance Interest Principal Payment Balance 1 0.00 0.00 0.00 0.00 0.00 2 0.00 0.00 0.00 0.00 0.00 3 0.00 0.00 0.00 0.00 0.00 4 0.00 0.00 0.00 0.00 0.00 5 0.00 0.00 0.00 0.00 0.00 6 0.00 0.00 0.00 0.00 0.00 7 0.00 0.00 0.00 0.00 0.00 8 0.00 0.00 0.00 0.00 0.00 9 0.00 0.00 0.00 0.00 0.00 10 0.00 0.00 0.00 0.00 0.00 11 0.00 0.00 0.00 0.00 0.00 12 0.00 0.00 0.00 0.00 0.00 13 0.00 0.00 0.00 0.00 0.00 14 0.00 0.00 0.00 0.00 0.00 15 0.00 0.00 0.00 0.00 0.00 16 0.00 0.00 0.00 0.00 0.00 17 0.00 0.00 0.00 0.00 0.00 18 0.00 0.00 0.00 0.00 0.00 19 0.00 0.00 0.00 0.00 0.00 20 0.00 0.00 0.00 0.00 0.00 21 0.00 0.00 0.00 0.00 0.00 5
Sample G Semi-Annual Report A NetWork Kansas referral coordinator will contact the business in approximately six months to obtain a SEMI-ANNUAL REPORT which is an updated snapshot of the business, and every six months until further notice. COMPANY INFORMATION Company name: Entity type: SEMI-ANNUAL SNAPSHOT OF COMPANY Full-time employees (headcount, including owners working full time in the business): Part-time employees (headcount and hours worked week): Annual revenue: Annual net income/(loss): If applicable, Full-time jobs created as result of fund award & average salary of job: If applicable, Part-time jobs created as result of fund award & average wage of job: Report shall include details addressing the following: 1. Describe the progress of the business during the period: 2. Have any significant problems been encountered during the last six months that have affected this business? If so, describe each problem, the resulting impact on the business, and the action(s) you have taken to assist or solve the problem(s). 3. Describe the technical assistance provided by NetWork Kansas partners during the reporting period. 4. Are there any additional NetWork Kansas partners who might be able to assist the business? 5. Are you aware of any additional benefits to Kansas that have occurred as a result of this project (for example, increased business for your suppliers)? If yes, please explain. 6