Hoosier Equipment Lease Purchase Program Application

Qualified Entity Name*
Federal Tax Identification Number*
Contact Name*

First Name Last Name
Contact Address
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
County
Is Billing Address Different than Contact?

YesNo
Billing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number*

Area Code Phone Number
Fax

Area Code
Email*
example@example.com
Were you referred to the HELP program by another unit of government?*

YesNo
If so, who referred you?*

Equipment Information
Equipment Description (year, make, model)*
What Essential Function does the Proposed Equipment Perform?*

Financing Information
1) Equipment Cost*
2) Down Payment Amount*
3) Trade-in Amount*
4) Amount Requested*
5) Estimated Delivery Date*

MonthDay Year
Date
6) Financing Term*
7) Payment Frequency*

AnnualSemi-AnnualQuarterlyMonthly
8) First Lease Payment Date*

MonthDay Year
Date
9) Preferred Closing Date*

MonthDay Year
Date
10) Name of fund used to pay for equipment*
11) Cash Balance of Fund used to Pay for the Equipment*