Healthcare

Borrower*

Application Date*

Originator*

Application Date*

LOAN INFORMATION

Loan Name/Description *

Recourse PreferenceRecourseNon-RecourseNegotiable

Loan PurposePurchaseRefinanceConstruction

If Purchase, Purchase Price*

Closing Date*

If Refinance, Loan Balance*

Interest Rate*

TypeFixedVariable

Cost of Recent Improvements*

Improvements DocumentedYesNoUnknown

If Construction, Construction Cost + Land*

Completion Date*

BORROWER INFORMATION

Primary Contact*

Contact Email*

Address*

City*

State*

Zip*

Phone*

Fax*

Net Worth*

FICO Score*

Bankruptcy?YesNo

PROPERTY INFORMATION

Property Name*

No of Buildings*

Property SubtypeNursing HomeCongregate CareAssisted LivingOther (specify)

Property Management Contract in place?YesNo

Land Area*

Last Appraised Value*

Last Sale Price*

Last Appraisal Date*

Date of Last Sale*

Property Attributes

Cafeterias*

Laundry Rooms*

Pools*

Clubhouses*

Exercise Rooms*

Nursing Stations*

Security Gates*

Rec Areas*

Surrounding Land Use

Light Industrial*

Heavy Industrial*

Industrial Park*

Office*

Residential*

Other (specify)*

BUILDING INFORMATION

Building Address*

City*

State*

Zip*

Number of Stories*

Year Built*

Year Renovated*

Overall AppearanceAverageAboveBelow

Air Conditioning*

Sprinklered*

Flat RoofYesNo

T-111 ExteriorYesNo

Est Market Vacancy*

Gross Building Area*

Net Rental Area*

Rent Roll

Unit Type ** Assisted Living (AL), Independent Living (IL), Skilled Nursing (SN), Intermediate Care (IC), Sub-Acute Care (SC)

Unit #	Unit Type**	# of occupied beds	# of vacant beds	Total occupied area (SF)	Total vacant area (SF)	Avg monthly rent per bed	Est market rent per bed	% of month to month	UTILITY	STORAGE	PARKING	MEALS	TRANS	LANDS	HSKEEP
1

Income & Expenses Statement

3 Previous Yrs

Current YTD

Year1*

Year2*

Year3*

Year4*

Year1 PrivatePay

Year2 PrivatePay*

Year3 Private Pay*

Current YTD Private Pay*

Trailing 12 months Private Pay*

Adjustments Private Pay*

Final Private Pay

Private Pay Notes

Year 1 Medicare/Medicaid*

Year2 Medicare/Medicaid*

Year3 Medicare/Medicaid*

Current YTD Medicare/Medicaid*

Trailing Medicare/Medicaid*

Adjustment Medicare/Medicaid*

Final Medicare/Medicaid*

Medicare/Medicaid Notes*

Year1 Nursing/Medical Income*

Year2 Nursing/Medical Income*

Year3 Nursing/Medical Income*

Current YTD Nursing/Medical Income*

Trailing Nursing/Medical Income*

AdjustmentNursing/Medical Income*

Final Nursing/Medical Income*

Nursing/Medical Income Notes*

Year1 Meals Income*

Year2 Meals Income*

Year3 Meals Income*

Current YTD Meals Income*

Trailing Meals Income *

Adjustment Meals Income*

Final Meals Income*

Meals Income Notes*

Year1 Other Income*

Year2 Other Income*

Year3 Other Income*

Current YTD Other Income*

Trailing Other Income*

Adjustment Other Income*

Final Other Income*

Other Income Notes*

Year1 Vacancy and Collection Loss*

Year2 Vacancy and Collection Loss*

Year3 Vacancy and Collection Loss*

Current YTD Vacancy and Collection Loss*

Trailing Vacancy and Collection Loss*

Adjustment Vacancy and Collection Loss*

Final Vacancy and Collection Loss*

Vacancy and Collection Loss Notes*

Year1 Effective Gross Income*

Year2 Effective Gross Income*

Year3 Effective Gross Income*

Current YTD Effective Gross Income*

Trailing Effective Gross Income*

Adjustment Effective Gross Income*

Final Effective Gross Income*

Effective Gross Income Notes*

Year1 Real Estate Taxes*

Year2 Real Estate Taxes*

Year3 Real Estate Taxes*

Current YTD Real Estate Taxes*

Trailing Real Estate Taxes*

Adjustment Real Estate Taxes*

Final Real Estate Taxes*

Real Estate Taxes Notes*

Year1 Property Insurance*

Year2 Property Insurance*

Year3 Property Insurance*

Current YTD Property Insurance*

Trailing Property Insurance*

Adjustment Property Insurance*

Final Property Insurance*

Property Insurance Notes*

Year1 Utilities*

Year2 Utilities*

Year3 Utilities*

Current YTD Utilities*

Trailing Utilities*

Adjustment Utilities*

Final Utilities*

Utilities Notes*

Year1 Repairs and Maintenance*

Year2 Repairs and Maintenance*

Year3 Repairs and Maintenance*

Current YTD Repairs and Maintenance*

Trailing Repairs and Maintenance*

Adjustment Repairs and Maintenance*

Final Repairs and Maintenance*

Repairs and Maintenance Notes*

Year1 Management Fees*

Year2 Management Fees*

Year3 Management Fees*

Current YTD Management Fees*

Trailing Management Fees*

Adjustment Management Fees*

Final Management Fees*

Management Fees Notes*

Year1 Payroll and Benefits*

Year2 Payroll and Benefits*

Year3 Payroll and Benefits*

Current YTD Payroll and Benefits*

Trailing Payroll and Benefits*

Adjustment Payroll and Benefits*

Final Payroll and Benefits*

Payroll and Benefits Notes*

Year1 Advertising and Marketing*

Year2 Advertising and Marketing*

Year3 Advertising and Marketing*

Current YTD Advertising and Marketing*

Trailing Advertising and Marketing*

Adjustment Advertising and Marketing*

Final Advertising and Marketing*

Advertising and Marketing Notes*

Year1 Professional Fees*

Year2 Professional Fees*

Year3 Professional Fees*

Current YTD Professional Fees*

Trailing Professional Fees*

Adjustment Professional Fees*

Final Professional Fees*

Professional Fees Notes*

Year1 General and Administrative*

Year2 General and Administrative*

Year3 General and Administrative*

Current YTD General and Administrative*

Trailing General and Administrative*

Adjustment General and Administrative*

Final General and Administrative*

General and Administrative Notes*

Year1 Room Exp-House Keeping*

Year2 Room Exp-House Keeping*

Year3 Room Exp-House Keeping*

Current YTD Room Exp-House Keeping*

Trailing Room Exp-House Keeping*

Adjustment Room Exp-House Keeping*

Final Room Exp-House Keeping*

Room Exp-House Keeping Notes*

Year1 Meal Expense*

Year2 Meal Expense*

Year3 Meal Expense*

Current YTD Meal Expense*

Trailing Meal Expense*

Adjustment Meal Expense*

Final Meal Expense*

Meal Expense Notes*

Year1 Other Expense*

Year2 Other Expense*

Year3 Other Expense*

Current YTD Other Expense*

Trailing Other Expense*

Adjustment Other Expense*

Final Other Expense*

Other Expense Notes*

Year1 Ground Rent*

Year2 Ground Rent*

Year3 Ground Rent*

Current YTD Ground Rent*

Trailing Ground Rent*

Adjustment Ground Rent*

Final Ground Rent*

Ground Rent Notes*

Year1 Total Operating Expenses*

Year2 Total Operating Expenses*

Year3 Total Operating Expenses*

Current YTD Total Operating Expenses*

Trailing Total Operating Expenses*

Adjustment Total Operating Expenses*

Final Total Operating Expenses*

Total Operating Expenses Notes*

Year1 Net Operating Income*

Year2 Net Operating Income*

Year3 Net Operating Income*

Current YTD Net Operating Income*

Trailing Net Operating Income*

Adjustment Net Operating Income*

Final Net Operating Income*

Net Operating Income Notes*

Year1 Cap Ex (Repl Reserves)*

Year2 Cap Ex (Repl Reserves)*

Year3 Cap Ex (Repl Reserves)*

Current YTD Cap Ex (Repl Reserves)*

Trailing Cap Ex (Repl Reserves)*

Adjustment Cap Ex (Repl Reserves)*

Final Cap Ex (Repl Reserves)*

Cap Ex (Repl Reserves) Notes*

Year1 Extraordinary Capital Exp*

Year2 Extraordinary Capital Exp*

Year3 Extraordinary Capital Exp*

Current YTD Extraordinary Capital Exp*

Trailing Extraordinary Capital Exp*

Adjustment Extraordinary Capital Exp*

Final Extraordinary Capital Exp*

Extraordinary Capital Exp Notes*

Year1 Total Capital Items*

Year2 Total Capital Items*

Year3 Total Capital Items*

Current YTD Total Capital Items*

Trailing Total Capital Items*

Adjustment Total Capital Items*

Final Total Capital Items*

Total Capital Items Notes*

Year1 Net Cash Flow*

Year2 Net Cash Flow*

Year3 Net Cash Flow*

Current YTD Net Cash Flow*

Trailing Net Cash Flow*

Adjustment Net Cash Flow*

Final Net Cash Flow*

Net Cash Flow Notes*

Healthcare

In Business Since 1980

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