ACCOUNTS RECEIVABLE FINANCING PRELIMINARY APPLICATION

 HEALTH CAPITAL INVESTORS, INC.

545 Fifth Avenue - 9th Floor - New York, NY  10017

Telephone:  212-421-4040 - Facsimile:  212-421-7171
Legal Name of Entity:
Address of Central Office:
Name of Contact Person:
Title:
Telephone:
Facsimile:
Address of all locations and other names used, if applicable:
Tax ID #'s: 
Details of Business and Ownership Structure:

FINANCIAL AND OPERATIONAL DATA:

1.  The latest two years of financial statements (audited, if available), most recent interim financial statement, and the latest two years of corporate tax returns.

2.  An overview of the company and a description of its management team.
3.  Desired amount of financing and proposed use of proceeds:
4.  Outstanding debt and the asset(s) it is encumbering, if any:
5.  A current Aged Trial Balance of your Accounts Receivable in 30-day increments broken out by payor type (i.e. Medicaid, Medicare, Commercial Insurance, etc.), in the form as follows:

 

Payor Class

Days Outstanding
0-30 31-60 61-90 91-120 121-150 151-180 180+
Medicare                            
Medicaid                            
Blue Cross/Shield                            
Commercial Ins.                            
HMO/PPO                            
Self-Pay                            
Workers Comp.                          
Other (Specify)