Highland Public - Application Form

MUNICIPAL EQUIPMENT LEASE/FINANCING


Full Legal Name of Municipal Entity:

Name and Address of Using Department
Department Name
Address 1:
Address 2:
City:	State:	Zip Code:
Phone Number:	-
Email:
Billing Address (if different from above address)
Address 1:
Address 2:
City:	State:	Zip Code:
ATTN:

Name of Person that will sign the documents:
Title of Person that will sign the documents:
Person that will attest to signature of documents: (This person must be able to verify that signatures are proper)
Title of person that will attest to signature:

Federal Tax ID #:

Insurance Company Name: (Content Insurance Agency)
Telephone Number:	-
Contact Name:
Policy Number:
Date municipal entity was established:
	year in 4-digit format - 20xx

Is the new equipment replacing existing?

Yes

If yes, please state how long you have used the current equipment and the reason for acquiring the new equipment:

Do you currently owe anything on the existing equipment?

Yes

Depending on the size of your request, financial statement/budget reports may be required.

When does your Fiscal Year begin?

Current Year

Prior Year

Total Revenues:

$ - no commas

Total Expenditures:

$ - no commas

Fund Balance:

$ - no commas

What fund will the payments be made from:

General or Special (Please Specify):

General

Special

Has your Municipality ever been in Default or Non-Appropriated on a Municipal financial arrangement?

Yes

If yes please provide details of why this happened.

Failure to consummate this transaction once credit approval is granted and the documents are drafted and delivered to your municipality will result in a $350 documentation fee bei ng assessed. This fee will NOT be charged if the transaction is closed and funded.

Completed By:
Title:
Date:
Vendor:
Sales Rep:
Phone No :	-

Equipment: (List examples: Fire Trucks, hoses, school desks)

Equipment Cost: $ - no commas

Requested Term:

If multiple vendors, please include a copy of each vendor's information.