1. For your benefit, please enter all information as completely as possible.
2. All quotes are subject to payor credit, UCC search and underwriting review.
3. We will contact you with a quote within 1-2 business days or to request further information as necessary.

If you prefer, you may submit this form by printing and faxing to 765-768-4121.

Contact Information

Note Seller's Name (First & Last):
Street Address:
City:   State:   Zip:
Home Phone #:   Work Phone #:
Best Time to Contact:
Fax Phone #:
E-mail Address:

Payor Information: (the note payor)

Payor Name:   Co-Payor Name:
Payor Address:   City:   State:   Zip:
**Payor SSN #:   **Co-Payor SSN #:
**(This is important for an accurate quote. If you have any questions regarding this, please note below.)

                                            Credit Of The Payor:
                  A   B   C   D   Unknown

Note Information: (this is the minimum information necessary for evaluation of your note)

Original Note Amount: $
Current Note Balance: $
Interest Rate: % Note Term:
Monthly Payment: $
Balloon Payment: $   Balloon Due Date:
First Payment Due Date:
Number of Payments Made:
Number of Payments Remaining:
Next Payment Due Date:
Are Payments Current?: Please Select Yes No

Is Payor a Corporation?: Please Select Yes No

Is Note Personally Guaranteed?: Please Select Yes No

Business Information:

Selling Price: $   Down Payment: $  

Break Down:   Equipment $   Inventory $   Goodwill $
Date of Sale:      Current Business Name:   
Business Address:   City:   State:   Zip:
Business Description:   Position of Note: Select First Lien Second Lien

Business Location is: Please Select Owned by Payor Leased by Payor    If Leased - - Expires When?

Give Terms of Any Lease Renewal Options: 
Qualifications of Payor to Operate Business: 

Describe Business Location and Area: 

How Long Has Business Operated at This Location?

*** If this note is Junior to another loan(s),
What is the approximate balance on the senior loan(s)? $

Please Select the Statement Below That Best Describes Your Interests.

I may consider selling only a portion of the note to meet my financial needs.
I am only interested in selling the whole note and getting the most cash I can.

Additional Information or Comments:

How did you find us? Please Select Web Search Mailer TV Commercial News Paper Ad Friend

Thank you for the opportunity to evaluate your note. We will respond to you within 1-2 business days.