Factoring DELMarVA Judgment Services

Accounts Receivable & Invoices Worksheet

*Bold fields are required*
Client Profile
*Email:*
*Legal Business Name:*
*Address:*
*City:*
*State*
*Zip:*
*Phone:*
Cell #:
*Fax:*
Website:
*Best time to reach you:*
*How did you hear of us?*

*Does the company*
Other locations:
*Landlord's Name:*
*Landlord's Phone #:*
*Landlord's Address:*
*Monthly Rent:$*
Company Information
*Entity:*
*Date Started:*
*Type of Business:*
*# of Employees:*
*Employer ID#:*
*Any Past Due Taxes?*
*If yes, explain:*
Has a lien been filed?
Shareholders/Officers (if more than four, please attach seperate page):
Shareholder/Officer #1
*Name:*
*Title:*
*Ownership %:*
*Home Address:*
*City:*
*State:*
*Zip:*
*DOB:*
*Phone:*
*SSN:*
*Driver License #:*
*State:*
Shareholder/Officer #2
Name:
Title:
Ownership %:
Home Address:
City:
State:
Zip:
DOB:
Phone #:
SSN:
Driver License #:
State:
Shareholder/Officer #3
Name:
Title:
Ownership %:
Home Address:
City:
State
Zip:
DOB:
Phone #:
SSN:
Driver License #:
State:
Shareholder/Officer #4
Name:
Title:
Ownership %:
Home Address:
City:
State:
Zip:
DOB:
Phone #:
SSN:
Driver License #:
State:
Bank Reference (if more than one bank, please attach separate page):
*Name of Bank:*
*Contact:*
*Address:*
*Phone #:*
*Account #:*
*Since:*
Loans?:
Collateral:
Receivables Information
*Monthly Revenues:$*
*Anticipated Monthly Working Capital Needs:$*
*Has the Company Financed It's A/R Before?:*
When:
With Whom:?
*Approximate Number of Invoices Per Month:*
*Any "work in progress" billing?*
*What % of Total?*
*Invoice Preparation Frequency:*
*Who prepares your Invoicing:?*
*Do you require Purchase Orders from your clients:?*
*What other documentation do you require:*
*What documentation is required by your clients to accompany your invoices:?*
*Internal Accounting Software used:*
*Do you require Credit Applications from your clients:?*
*What information do you require?*
Support Information
*Accountant:*
*Contact:*
*Address:*
*City:*
*State:*
*Zip:*
*Phone:*
*Fax:*
*Insurance Agent:*
*Contact:*
*Address:*
*City:*
*State:*
*Zip:*
*Phone:*
*Fax:*
*Attorney:*
*Contact:*
*Address:*
*City:*
*State:*
*Zip:*
*Phone:*
*Zip:*
I understand this is not an application for credit. The intent of this form is for us to determine if a relationship between DELMarVA Judgment Services and/or its assigns and you and/or your company would be mutually beneficial. By submitting the required form, you authorize DELMarVA Judgment Services and/or its assigns to access any credit reporting agencies for which we are a member in your security interest under any agreements and transactions relating to DELMarVA Judgment Services and you and/or your firm. Your information is held in the strictest confidence and is used to help you achieve your goals in an expeditious and professional manner.
*Your name:*
Signature (if faxing or mailing):
*Today's date:*
Support Documentation
Please compile the following information for our review. If a requested item is not currently available, please provide a brief explanation.
	Copy of DBA filing or, if incorporated copy of Articles of Incorporation.
	Copy of last two (2) quarter-end 941 Payroll Tax Reports with proof of payment.
	Last year-end Financial Statement.
	Most recent Interim Financial Statement.
	Most recent Tax Return filed.
	Current Aging of Accounts Receivables.
	Current Aging of Accounts Payables.
	Master Customer List (includes addresses and phone numbers).
	Copies of Invoice Documentation for financing (Complete invoice documentation required - Purchase Order, Contract, Proof of Delivery, and/or other supporting documentation for the invoices).
	Transportation Companies: Copy of your ICC Authority, DOT Motor Carrier (MC) Certificate, Current Insurance Binder.
Comments:	Any other comments?
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