Accounts Receivable Factoring Application

Many businesses and fast-growing companies do not have the option to wait 30, 60, or 90 days to receive payment from their clients or customers. They need cash now. We understand that most companies also do not have the time to fill out lengthy applications or to wait a long time for a response. We welcome the opportunity to begin factoring your accounts receivables invoices and our application process is a quick one. For your convenience and to enable you to receive a quick response, we have streamlined our application to 4 short pages. We are pleased to provide you with our application.

Download the application here. Or if you prefer use our secure online form below.

Company Information
Full Business Name:
Legal Name: (If Different)
Business Address:
Street Address Address Line 2 City State ZIP Code
Business Phone:
Business Fax:
Email:
Structure
- C Corporation
- S Corporation
- DBA
- Partnership
- Sole Proprietorship
- LLC
Years in Business:
If Corporation, State of Incorporation:
If doing business at places other than Principal Place of Business/Corporate Office, list all additional addresses:
Has there been a change of business name within the last five years:
If yes, list names used:
Has there been a change of ownership:
If yes, explain:
Describe primary source(s) of business activity:
Tax Information
Federal Tax ID Number:
State Tax Number:
All applicable Federal taxes have been filed through:
MM slash DD slash YYYY
Do you have any Federal or State taxes overdue:
If yes, have any liens been filed:
Are any Federal or State tax returns under audit:
If yes, explain:
Principal/Corporate Officer Information
Title:
Name:
First Last
Home Phone:
Home Address:
Street Address Address Line 2 City State ZIP Code
Social Security Number:
Date of Birth:
MM slash DD slash YYYY
Drivers License State:
Drivers License Number:
Has been convicted of a felony:
If yes, explain:
Title:
Name:
First Last
Home Phone:
Home Address:
Street Address Address Line 2 City State ZIP Code
Social Security Number:
Date of Birth:
MM slash DD slash YYYY
Drivers License State:
Drivers License Number:
Has been convicted of a felony:
If yes, explain:
Title:
Name:
First Last
Home Phone:
Home Address:
Street Address Address Line 2 City State ZIP Code
Social Security Number:
Date of Birth:
MM slash DD slash YYYY
Drivers License State:
Drivers License Number:
Has been convicted of a felony:
If yes, explain:
Professional Contacts
Where applicable, please provide us with the names, addresses, and phone numbers of your accountant, banker, attorney and insurance agent.
Accountant Firm:
Name:
First Last
Phone
Address:
Street Address Address Line 2 City State ZIP Code
Banker Firm:
Name:
First Last
Phone
Address:
Street Address Address Line 2 City State ZIP Code
Attorney Firm:
Name:
First Last
Phone:
Address:
Street Address Address Line 2 City State ZIP Code
Insurance Agent Firm:
Name:
First Last
Phone:
Address:
Street Address Address Line 2 City State ZIP Code
Trade References
Please provide us with three of the Business's suppliers.
Name:
Phone:
Contact(s):
Service/Product Provided:
Name:
Phone:
Contact(s):
Service/Product Provided:
Name:
Phone:
Contact(s):
Service/Product Provided:
Financial History
Has Business ever been subject to a repossession or order of Replevin:
Has Business ever declared bankruptcy:
Is Business or its principals Defendant(s) in any legal actions:
Are any Liens currently placed against Applicant's Accounts Receivable (or Accounts Receivable pledged as collateral):
Does Business have any outstanding business loans:
Name of Financial Institution:
Phone:
Address:
Street Address Address Line 2 City State ZIP Code
Loan Amount:
Collateral Pledged:
Has Business previously factored:
If yes, name of previous factor:
Authorization of Submission
- I represent and warrant that the information on this Application to US Funding, Inc. is true and correct to the best of my knowledge and no material information has been omitted. If a change occurs to materially affect my answers to the questions herein, I will so notify US Funding, Inc. immediately. Unless this happens, US Funding, Inc. may rely on this application as true and accurate as of the date below. US Funding, Inc. is authorized to check the Applicant's credit (including my personal credit, or the personal credit of the principals and/or officers of the Applicant) and make all other inquiries that US Funding, Inc. deems necessary to verify the accuracy of the statements made on this form and to determine my creditworthiness. This application and my attachments remain the property of US Funding, Inc.
Applicant's Full Name:
First Last
Co-Applicant's Full Name:
First Last
Comments
This field is for validation purposes and should be left unchanged.

Accounts Receivable Factoring Application

Company Information

Tax Information

Principal/Corporate Officer Information

Professional Contacts

Trade References

Financial History

Authorization of Submission

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