Funding Request Form

Company Letterhead

{{company_name}}

{{company_address}}

Phone: {{phone}}

Email: {{email}}

Website: {{website}}

Date and Reference

Date: {{date}}

Our Reference: {{our_reference}}

Recipient Details

To: {{funder_name}}

Attention: {{contact_person}}

Address: {{funder_address}}

Email: {{funder_email}}

Executive Summary

Provide a concise overview of your business, the purpose of this funding request, the amount requested, and how the funds will be utilised. Highlight key success factors and expected returns on investment or impact.

Business Overview

Legal Name of Business: {{legal_business_name}}

Trading Name (if different): {{trading_name}}

Registration Number: {{registration_number}}

Date of Establishment: {{date_of_establishment}}

Business Address: {{business_address}}

Nature of Business/Industry: {{nature_of_business}}

Brief History and Milestones: {{business_history}}

Funding Request Details

Amount of Funding Requested: {{amount_requested}}

Currency: {{currency}}

Purpose of Funding (e.g., working capital, expansion, equipment purchase): {{purpose_of_funding}}

Detailed breakdown of how funds will be utilised: {{fund_utilization_breakdown}}

Expected Timeline for Funding Utilisation: {{timeline_for_funds_use}}

Proposed Repayment Plan/Investment Return Structure: {{repayment_plan}}

Financial Projections

Attach detailed financial projections for the next {{projection_years}} years, including:

- Income Statements (Profit & Loss)

- Balance Sheets

- Cash Flow Statements

- Key Assumptions underlying projections: {{key_assumptions}}

Specify if attached separately as 'Appendix A: Financial Projections'.

Management Team

Key Management Personnel and their roles: {{management_team_roles}}

Relevant Experience and Qualifications: {{management_team_experience}}

Attach CVs of key management personnel as 'Appendix B: Management CVs'.

Declaration and Authorisation

I/We, the undersigned, declare that the information provided in this funding request and all accompanying documents is true and accurate to the best of my/our knowledge and belief. I/We understand that any false information may lead to the rejection of this application.

I/We authorise {{funder_name}} to make enquiries as deemed necessary to verify the information provided herein.

Signature Block

Signed for and on behalf of {{company_name}}:

_____________________________

Name: {{signer_name}}

Title: {{signer_title}}

Date: {{signature_date}}