Hoosier Equipment Lease Purchase Program Application

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

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Is Billing Address Different than Contact?

Yes No

Billing Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

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? *

Yes No
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 *

Month Day Year
Date
6) Financing Term *
7) Payment Frequency *

Annual Semi-Annual Quarterly Monthly
8) First Lease Payment Date *

Month Day Year
Date
9) Preferred Closing Date *

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