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Legal Company Name

Your Email

Phone Number

Federal Tax ID #

Business Address

Business Description (Brief)

Monthly Gross Billing

Average Monthly Collections

Net Collectable (Percentage)

License Numbers (NPI/Medicaid/Medicare) (Optional)

Are your Payroll taxes current?
YesNo

If no, what is your estimated balance?

Are your Federal/State taxes current?
YesNo

If no, what is your estimated balance?

Has your company ever been suspended or denied as a Medicaid/Medicare Licensure?
YesNo

Have any owners/officers filed for bankruptcy or have any judgments, tax liens, or pending lawsuits?
YesNo

Does your company have any commercial loans/liens against your Accounts Receivable?
YesNo

Principle/Owner Name, DOB, Address, % of Ownership

Current A/R Aging

Profit & Loss Reports (Current & Previous Year)

Tax Returns (Past 2 Years)

State Articles of Incorporation/Organization

Bank Statements

Miscellaneous Files

The foregoing information is true and correct to the best of my knowledge and is given to LightStar Financial Services, LLC and Heartland Capital Funding, LLC to induce LFS, LLC to consider entering into a factoring agreement with this company, or have this information assigned to another creditor. I/we have been expressively authorized to grant LFS, LLC or its agents to verify and investigate any and all the foregoing statements, including, but not limited to my/our credit worthiness and financial responsibility, in any way LFS, LLC chooses. I/we grant LFS, LLC the right to procure any and all credit reports pertaining to any party affiliated with the corporate applicant, including all principals of the applicant company. I/we grant LFS, LLC the right to request a consumer credit and/or background reports as necessary. This application authorizes LFS,LLC to file one or more Initial Financing Statements in any or all Uniform Commercial Code jurisdictions, which reflect the Applicants assets pledged and the collateral as "all assets" for the benefit of the financing application.