Legal Company Name
D.B.A. (if Applicable)
Present Address
City Sate Zip
Phone Fax Email
Contact Title
Structure Corporation Partnership Sole Proprietorship LLC Date Est.
Sate of Incorporation Date of Incorporation Federal Tax ID/SSN
Business Description
Has Client ever Factored receivables No Yes With Whom?
Does Client or its principals have any Judgments Liens Back Taxes Lawsuits
If yes to any of above, please explain
Does Client have any outstanding Loans? No Yes Name of Institution
Balance Owed? Are receivables pledged as collateral? Yes No
Name of Institution Address
Phone Contact Check Loan Account#
Please list clients five largest customers client wishes to factor. Customers will not be initially contacted.
Monthly Sales Average Invoice Name City State Phone
Ultimately will need the following:
a) Copy of articles of incorporation & By-Laws or Copy of Partnership Agreement b) Copy of Fictitious Name Filing (If Applicable) c) Accounts receivable Aging