Application for Financing

Applicants must be of Métis or Dene origin, resident in the Northwest Territories, and of the legal age of majority.

In the case of an organization or corporation, it must be 51% owned and effectively controlled by persons of Dene or Métis origin and who are resident in the Northwest Territories. Further, the organization or corporation must have its registered office in the Northwest Territories.

Please answer all questions as completely as possible and provide attachments if space is insufficient.

A detailed business plan outlining your business proposal may be required, and would benefit you greatly. A business plan outline is attached for your reference. Should you require additional information or assistance in completing your application, please contact us at telephone number (867) 873 9341, toll free 1-888-554-6333, or at Fax number (867) 766-3745.
 
1. Applicant Information
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Contact name:   Contact title:
 
  Mr. Mrs. Ms. Mis. Dr.
Business legal name:   Business operating name(s):
 
Residence phone:   Business Telephone:
 
E-mail:   Fax Telephone:
 
Web Address:    
   
   
Structure of business:
  Proprietorship Partnership Corporation Other
If Other Provide Details:
 
   
Mailing address: Community: Postal code:
     
Street or Legal Address: Community: Postal code:
Business’ Principal Financial Institution: (Name & Address)
Name:   Address:
 
     
Contact person:   Phone:
 
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2. Project Description
Attach any additional information that supports your proposal, such as a business plan, market plan, market study, feasibility study etc.

If the information called for is included in the attachments, please note such.

For existing businesses please attach financial statements for the last three fiscal years.
 
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The main purpose of this application is to:
Establish a new business Acquire a new business Expand an existing business
 
 
Briefly describe the project (What product or service will you be, or are you currently, providing?):


If this is application is for an existing business please provide a brief history:
     
Identify geographically, the market you will be targeting in carrying out your proposal:

Identify your competition:
Explain why you consider your proposal to be commercially viable and profitable:
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3. Project Cost & Financing

Please itemize major projected expenditures, and a proposed financing package. Total Costs must equal Total Financing.

MDDF is only able to finance projects where the applicant makes a minimum 15% commitment in equity.

For information on the various programs that MDDF offers please see the attached sheet.
 
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Estimated Cost of the Project
 Anticipated Financing of the Project
Capital    
Land $
Equity    
Cash $
Building $
Contributed Assets $
Equipment $
Contributions (Non-Repayable)
Other (specify)  
ABC, BDF, (specify)  
Operating    
FN&IYBP
Contribution		  $
Working Capital    
Debt    
Other (specify)  
FN&IYBP Loan $
 
ABYLF Loan $
   
 
MDDF Loan $
   
 
Other (specify) $
   
Total Cost: $
Total Financing: $
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1. Declaration
The undersigned hereby declare(s) that all the information provided herein and on the accompanying statements is to the best of my/our knowledge true, complete and correct and understand it will be used by MDDF to determine credit worthiness. The proceeds of the loan applied for will be used for business purposes and not for personal, family or household purposes

The undersigned further hereby declare(s) that I am of Aboriginal descent and/or represent a company/organisation that is majority Aboriginally owned and effectively Aboriginally controlled.

The undersigned further hereby declares that they have received a copy of MDDF’s privacy policy.

The undersigned further consent(s) to MDDF making any enquiries it deems necessary to reach a decision on this application, and consent(s) to the disclosure at any time of any credit information about me/us to any credit reporting agency or to any one with whom I/we have financial relations
Signature: Date:
     
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NWT Métis-Dene Development Fund Ltd.

Appendix ‘C’
 
General

To be filled out if your business is a partnership.

Please attach proof of aboriginal ancestry (status card, Métis local card, etc.)
 
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1. Ownership
     
Name: Percentage Ownership: Aboriginal or Non-Aboriginal:
Aboriginal Non-Aboriginal:
     
Name: Percentage Ownership: Aboriginal or Non-Aboriginal:
Aboriginal Non-Aboriginal:
     
Name: Percentage Ownership: Aboriginal or Non-Aboriginal:
Aboriginal Non-Aboriginal:
     
Name: Percentage Ownership: Aboriginal or Non-Aboriginal:
Aboriginal Non-Aboriginal:
     
Do you have a signed Partnership Agreement? (Attach copy if yes):
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2. Shareholder Information (complete for each principal shareholder, copy if necessary)
     
FirstName: LastName
Heritage: (Dene, Métis) Date of Birth:
Dene Métis Other
     
     
Social Insurance Number: Residence: How long at address:
Own Rent Others
     
Marital Status: Number of Dependants: Current Employer:
  Married Single
  Divorced Separated
  Widowed Common Law
     
Occupation: How long with Employer: Spouse’s Name:
     
Spouse’s Employer: Occupation: How long with Employer:
     
Your Principal Financial Institution (Name & Address):
     
Reference - provide the name, title, address and telephone number of at least 3 people whom we may contact. One of these should be familiar with your financial standing. The others should be familiar with your skills and business experience.
 
NB:Please complete Personal Information Sheet, Appendix ‘D’.
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3. Shareholder Information (complete for each principal shareholder, copy if necessary)
     
FirstName: LastName
Heritage: (Dene, Métis) Date of Birth:
Dene Métis Other
     
     
Social Insurance Number: Residence: How long at address:
Own Rent Others
     
Marital Status: Number of Dependants: Current Employer:
  Married Single
  Divorced Separated
  Widowed Common Law
     
Occupation: How long with Employer: Spouse’s Name:
     
Spouse’s Employer: Occupation: How long with Employer:
     
Your Principal Financial Institution (Name & Address):
     
Reference - provide the name, title, address and telephone number of at least 3 people whom we may contact. One of these should be familiar with your financial standing. The others should be familiar with your skills and business experience.
 
NB:Please complete Personal Information Sheet, Appendix ‘D’.
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4. Shareholder Information (complete for each principal shareholder, copy if necessary)
     
FirstName: LastName
Heritage: (Dene, Métis) Date of Birth:
Dene Métis Other
     
     
Social Insurance Number: Residence: How long at address:
Own Rent Others
     
Marital Status: Number of Dependants: Current Employer:
  Married Single
  Divorced Separated
  Widowed Common Law
     
Occupation: How long with Employer: Spouse’s Name:
     
Spouse’s Employer: Occupation: How long with Employer:
     
Your Principal Financial Institution (Name & Address):
     
Reference - provide the name, title, address and telephone number of at least 3 people whom we may contact. One of these should be familiar with your financial standing. The others should be familiar with your skills and business experience.
 
NB:Please complete Personal Information Sheet, Appendix ‘D’.
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5. Shareholder Information (complete for each principal shareholder, copy if necessary)
     
FirstName: LastName
Heritage: (Dene, Métis) Date of Birth:
Dene Métis Other
     
     
Social Insurance Number: Residence: How long at address:
Own Rent Others
     
Marital Status: Number of Dependants: Current Employer:
  Married Single
  Divorced Separated
  Widowed Common Law
     
Occupation: How long with Employer: Spouse’s Name:
     
Spouse’s Employer: Occupation: How long with Employer:
     
Your Principal Financial Institution (Name & Address):
     
Reference - provide the name, title, address and telephone number of at least 3 people whom we may contact. One of these should be familiar with your financial standing. The others should be familiar with your skills and business experience.
 
NB:Please complete Personal Information Sheet, Appendix ‘D’.
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Appendix D
 
Personal Financial Information for:
Please list and describe all assets and liabilities  
   
 
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1. ASSETS
Cash  
  Saving $
  Chequing $
  Total $
Cash Value of Life Insurance $
 
Vehicles          
  Make & Model   Year      
    Value $  
    Value $  
        Total $  
 
Real Estate Owned  
Description  
  $
  $
  Total $
 
Investments (Stocks & Bonds)
Market Value $ 
Accounts/Notes Receivable    
  Debtor's Name    
  $
  $
  Total $
Retirement Accounts (RRSP)    
  Description    
  $
  $
  Total $
Other Assets    
  Description    
  $
  $
  $
Total $
Total Assets (1) $
 
NET WORTH (Total Assets – Total Liabilities) $
 
  2. LIABILITIES
  Balance
  Personal line of credit $
  Bank Loans $
  Total $
 
       
  Vehicle Financed by   Balance
  $
  $
  Total $
       
  Mortgages on Real Estate financed by:   Balance
  $
  $
  Total $
 
  Credit Cards    
  Issued by   Balance
  $
  $
  $
  $
  Total $
       
  Other Obligations    
  Description   Balance
  $
  $
  $
  $
  Total $
  Total Liabilities (2) $
 
   
   
   
   
Income Sources    
  Gross Monthly Salary $
  Spouse's Gross Monthly Salary $
  Other Monthly Income $
  Total $
 
Sundry Personal Obligations
  Have you ever had an asset repossessed?
  Yes No  
If YES please provide details
       
  Are you a part to any claims or lawsuit?
  Yes No  
If YES please provide details
       
  Have you ever declared bankruptcy?
  Yes No  
If YES please provide details
       
  Do you owe Income Taxes for previous years?
  Yes No  
If YES please provide details
       
  Are you a co-signor, endorser, guarantor?
  Yes No  
If YES please provide details
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Appendix D
 
Personal Financial Information for:
Please list and describe all assets and liabilities  
   
 
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1. ASSETS
Cash  
  Saving $
  Chequing $
  Total $
Cash Value of Life Insurance $
 
Vehicles          
  Make & Model   Year      
    Value $  
    Value $  
        Total $  
 
Real Estate Owned  
Description  
  $
  $
  Total $
 
Investments (Stocks & Bonds)
Market Value $ 
Accounts/Notes Receivable    
  Debtor's Name    
  $
  $
  Total $
Retirement Accounts (RRSP)    
  Description    
  $
  $
  Total $
Other Assets    
  Description    
  $
  $
  $
Total $
Total Assets (1) $
 
NET WORTH (Total Assets – Total Liabilities) $
 
  2. LIABILITIES
  Balance
  Personal line of credit $
  Bank Loans $
  Total $
 
       
  Vehicle Financed by   Balance
  $
  $
  Total $
       
  Mortgages on Real Estate financed by:   Balance
  $
  $
  Total $
 
  Credit Cards    
  Issued by   Balance
  $
  $
  $
  $
  Total $
       
  Other Obligations    
  Description   Balance
  $
  $
  $
  $
  Total $
  Total Liabilities (2) $
 
   
   
   
   
Income Sources    
  Gross Monthly Salary $
  Spouse's Gross Monthly Salary $
  Other Monthly Income $
  Total $
 
Sundry Personal Obligations
  Have you ever had an asset repossessed?
  Yes No  
If YES please provide details
       
  Are you a part to any claims or lawsuit?
  Yes No  
If YES please provide details
       
  Have you ever declared bankruptcy?
  Yes No  
If YES please provide details
       
  Do you owe Income Taxes for previous years?
  Yes No  
If YES please provide details
       
  Are you a co-signor, endorser, guarantor?
  Yes No  
If YES please provide details
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Appendix D
 
Personal Financial Information for:
Please list and describe all assets and liabilities  
   
 
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1. ASSETS
Cash  
  Saving $
  Chequing $
  Total $
Cash Value of Life Insurance $
 
Vehicles          
  Make & Model   Year      
    Value $  
    Value $  
        Total $  
 
Real Estate Owned  
Description  
  $
  $
  Total $
 
Investments (Stocks & Bonds)
Market Value $ 
Accounts/Notes Receivable    
  Debtor's Name    
  $
  $
  Total $
Retirement Accounts (RRSP)    
  Description    
  $
  $
  Total $
Other Assets    
  Description    
  $
  $
  $
Total $
Total Assets (1) $
 
NET WORTH (Total Assets – Total Liabilities) $
 
  2. LIABILITIES
  Balance
  Personal line of credit $
  Bank Loans $
  Total $
 
       
  Vehicle Financed by   Balance
  $
  $
  Total $
       
  Mortgages on Real Estate financed by:   Balance
  $
  $
  Total $
 
  Credit Cards    
  Issued by   Balance
  $
  $
  $
  $
  Total $
       
  Other Obligations    
  Description   Balance
  $
  $
  $
  $
  Total $
  Total Liabilities (2) $
 
   
   
   
   
Income Sources    
  Gross Monthly Salary $
  Spouse's Gross Monthly Salary $
  Other Monthly Income $
  Total $
 
Sundry Personal Obligations
  Have you ever had an asset repossessed?
  Yes No  
If YES please provide details
       
  Are you a part to any claims or lawsuit?
  Yes No  
If YES please provide details
       
  Have you ever declared bankruptcy?
  Yes No  
If YES please provide details
       
  Do you owe Income Taxes for previous years?
  Yes No  
If YES please provide details
       
  Are you a co-signor, endorser, guarantor?
  Yes No  
If YES please provide details
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Appendix D
 
Personal Financial Information for:
Please list and describe all assets and liabilities  
   
 
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1. ASSETS
Cash  
  Saving $
  Chequing $
  Total $
Cash Value of Life Insurance $
 
Vehicles          
  Make & Model   Year      
    Value $  
    Value $  
        Total $  
 
Real Estate Owned  
Description  
  $
  $
  Total $
 
Investments (Stocks & Bonds)
Market Value $ 
Accounts/Notes Receivable    
  Debtor's Name    
  $
  $
  Total $
Retirement Accounts (RRSP)    
  Description    
  $
  $
  Total $
Other Assets    
  Description    
  $
  $
  $
Total $
Total Assets (1) $
 
NET WORTH (Total Assets – Total Liabilities) $
 
  2. LIABILITIES
  Balance
  Personal line of credit $
  Bank Loans $
  Total $
 
       
  Vehicle Financed by   Balance
  $
  $
  Total $
       
  Mortgages on Real Estate financed by:   Balance
  $
  $
  Total $
 
  Credit Cards    
  Issued by   Balance
  $
  $
  $
  $
  Total $
       
  Other Obligations    
  Description   Balance
  $
  $
  $
  $
  Total $
  Total Liabilities (2) $
 
   
   
   
   
Income Sources    
  Gross Monthly Salary $
  Spouse's Gross Monthly Salary $
  Other Monthly Income $
  Total $
 
Sundry Personal Obligations
  Have you ever had an asset repossessed?
  Yes No  
If YES please provide details
       
  Are you a part to any claims or lawsuit?
  Yes No  
If YES please provide details
       
  Have you ever declared bankruptcy?
  Yes No  
If YES please provide details
       
  Do you owe Income Taxes for previous years?
  Yes No  
If YES please provide details
       
  Are you a co-signor, endorser, guarantor?
  Yes No  
If YES please provide details
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