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Your Name

Law Firm Name

Phone

LAW FIRM INFORMATION

Ownership Structure

Year Founded

Number of Equity Partners

Number of Employees

Amount of Funding Requested

Primary Expected Use of Proceeds

Be specific

Approximate Revenue, Net of all Payments to Clients and Co-counsel

Year

2021

2022

2023

2024 EST

Current Docket Composition

Legal Matter

Number of Clients

Estimated Fees

Dollar Amount of SBA COVID Relief secured Debt on Law Firm (EIDL)

Dollar Amount of non-SBA COVID Relief secured Debt and Fee Advances on Law Firm (Bank Debt, Specialized Financing, etc.)

Does the law firm currently owe back taxes?

Yes

Does the law firm currently have malpractice insurance?

Yes

EQUITY PARTNER INFORMATION

Names of Additional Equity Partners

1. Do you currently owe back taxes personally?(Required)

Yes

2. Have you or an entity controlled by you ever filed bankruptcy?(Required)

Yes

3. Has any creditor ever foreclosed on or repossessed any asset of yours and/or any entity controlled by you?(Required)

Yes

4. Have you or any entity controlled by you settled a balance with any creditor for less than the full balance due?(Required)

Yes

5. Have you ever been arrested or the subject of a criminal investigation?(Required)

Yes

6. Have you ever been disciplined by or do you have a pending disciplinary action with a State Bar?(Required)

Yes

If you answered “Yes” to any of the Equity Partner Information, please provide details

How did you hear about us?

Disclaimer

The information collected on this application will only be used to respond to you about your request for financing. We will not share your information with anyone outside of our organization. Financing with B.E. Blank & Company will not appear on personal credit, nor will your application for financing impact your credit score.

Consent

I understand that I have the right to request additional disclosures concerning the nature and scope of B.E. Blank & Company's credit review, upon written request, within a reasonable timeframe.

I understand that B.E. Blank & Company may reasonably rely upon all the information disclosed within this application and any all attachments in all respects.

I understand that written or verbal communications by the partners, employees or affiliates of B.E. Blank & Company do not themselves constitute offers for financing. I understand further that all offers for financing are contingent upon the approval of the investment team of B.E. Blank & Company after completion of due diligence by its legally designated employees, which are validated through formal financing agreements.

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