Funding Application

The LCF Group Funding Application

Business Legal Name

Business DBA Name

Legal Entity Proprietor

Business Start Date

State of Incorporation

Federal Tax ID # (EIN)

Physical Address

City

State

Zip Code

Business Phone Number

Mobile Number

Email Address

Website URL

Type of Business

Property Ownership

Rent/Mortgage Payment

Purpose of Working Capital?

Do you have a current advance or loan?

If yes, what is the balance?

Held With:

Original Advance Amount

Payback Amount

Holdback %

Current Credit Card Processor

Average Monthly Credit Card Volume

Gross Annual Sales

Owner Name

Title

Ownership %

Home Phone

Date of Birth

Social Security Number

Home Address

City

State

Zip Code

The Merchant and Owner(s)/Officer(s) identified above (individually, and "Applicant") each represents, acknowledges and agrees that (1) all the information and documents provided to The LCF Group ("Representative") including credit card processor statements are true, accurate and complete, (2) Applicant will immediately notify Representative of any change in such information or financial condition, (3) Applicant authorizes Representative to disclose all information and documents that Representative may obtain including credit reports to the other persons or entities (collectively, "Assignees") that may be involved with or acquire commercial loans having daily repayment features or purchases of future receivables, including Merchant Cash Advance transactions, including without limitation the application therefor (collectively, "Transactions"), and each Assignee is authorized to use such information and documents, and share such information and documents with other Assignees, in connection with potential Transactions, (4) Representative and each Assignee will rely upon the accuracy and completeness of such information and documents, (5) Representative, Assignees, and each of their representatives, successors, assigns and designees (collectively, "Recipients") are authorized to request and receive and investigative reports, credit reports, statements from creditors or financial institutions, verification information, or any other information that a Recipient deems necessary, (6) Applicant waives and releases and claims against Recipients and any other information-providers arising from any act or omission relating to the requesting, receiving, or release of information, and (7) each Owner/Officer represents that he or she is authorized to sign this form on behalf of Merchant. A copy of this authorization may be accepted as an original.

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Signature

Signed Date