MCIDA | Application

Application

General Information

Project Name: (required)
Describe the Project including street address, location, purpose, and the facilities to be financed (including land, buildings, equipment, etc) for each project site or location. (required)
Give a brief description of why the project is eligible for financing through the Authority including the project's public purpose. (required)
Anticipated Date to Come to the Board:Date format: mm/dd/yyyy
Anticipated Closing Date: (required)Date format: mm/dd/yyyy
Maximum Amount of Requested Financing: (not to exceed) (required)
Applicant's Legal Name: (required)
Applicant's form of Business (corporation, non-profit, Limited Liability Company, etc.) and State established (If applying as a non-profit, please attach 501(c)(3) IRS Determination Letter): (required)
Street Address: (required)

City: (required)

State: (required)

Zip Code: (required)

Phone Number:

Fax Number:

Applicant's Primary Contact: (required)
Street Address:

City:

State:

Zip Code:

Phone Number: (required)

Cell Phone:

Email: (required)

Applicant's Secondary Contact:
Street Address:

City:

State:

Zip Code:

Phone Number:

Cell Phone:

Email:
Provide a Brief Description of the Applicant: (required)
Are there any potential conflicts of interests among the Applicant, its officers, management or directors, and the other parties to the proposed financing, including, but not limited to, the Authority, the County of Maricopa, or their officers or agents? YesNo
If yes, please describe the conflict.
Are there any executives, managing officers, general partners or directors of the Applicant who have been convicted – or are currently under federal indictment or complaint alleging commission – of a felony or of a misdemeanor involving moral turpitude or a civil or criminal offense relating to the conduct of the business, of the Applicant or any similar person or from the issuance, sale, or solicitation for sale of any type of security? YesNo
If yes, please describe the situation and the person(s) involved.
Describe any material litigation or contingent liabilities involving the Applicant or, if the Applicant is a partnership, its general partners or, if the Applicant is a limited liability company, its managers and/or members.

Proposed Finance Team

Applicant's Counsel

Firm Name:
Street Address:

City:

State:

Zip Code:

Phone Number:

Cell Phone:

Firm's Primary Contact:

Phone Number:

Cell Phone:

Email Address:
Firm's Secondary Contact:

Phone Number:

Cell Phone:

Email Address:

Bond Counsel

Firm Name:
Street Address:

City:

State:

Zip Code:

Phone Number:

Fax Number:

Firm's Primary Contact:

Phone Number:

Cell Phone:

Email Address:

Firm's secondary Contact:

Phone Number:

Cell Phone:

Email Address:

Bond Purchaser or Underwriter

Company Name:
Street Address:

City:

State:

Zip Code:

Phone Number:

Fax Number:

Company's Primary Contact:

Phone Number:

Cell Phone:

Email Address:
Company's secondary Contact:

Phone Number:

Cell Phone:

Email Address:

Trustee (if applicable)

Trustee Name:
Street Address:

City:

State:

Zip Code:

Phone Number:

Fax Number:

Trustee's Primary Contact:

Phone Number:

Cell Phone:

Email Address:
Trustee's secondary Contact:

Phone Number:

Cell Phone:

Email Address:

Project Finance Information

Describe the proposed financing structure including the type of sale of the bonds, whether this is a public or private offering, and whether it is to repay or refinance bonds: (required)

Equity (cash):

Equity (non-cash):

Describe:

Equity (non-cash):

Describe:

Equity (non-cash):

Describe:

Equity (non-cash):

Describe:

Bond Proceeds:

Describe:

Other:

Describe:

Other:

Describe:

Other:

Describe:

Other:

Describe:

Total:

Provide an Estimate of the Uses of Funds:

Land:

Construction:

Describe:

Equipment:

Describe:

Other:

Describe:

Other:

Describe:

Other:

Describe:

Other:

Describe:

Cost of Issuance:

Describe:

Total:

If Applicant has incurred any expenditures listed above, please describe the particulars:

Please attach financials and/or a feasibility study. The Authority may request other information it deems necessary on the project or the Applicant.

Employment Plan

Please list the number, classification, and estimated salary range of jobs to be created or retained:
Briefly describe the procedures for recruiting, training, and placing new employees:

Confirmation

Application Date: (required)Date format: mm/dd/yyyy
Your Name: (required)
Title: (required)
Electronic Signature: (required)

Using your mouse cursor, sign your name in the box below.

Electronic Communications

You acknowledge and agree that any agreements made by you electronically satisfy any legal requirement that such communications be made in writing.

When you complete this Application, you will be required to acknowledge your use and the validity of your electronic signature, and specifically that you are signing this Application with your electronic signature.

*Application Fee

Your Application will not be considered complete until you pay the $3,000 non-refundable Application fee. Please submit your Application fee by check, ACH, or wire transfer within two (2) days of submitting this Application.

Tax-Exempt Financing

Application

General Information

Proposed Finance Team

Applicant's Counsel

Bond Counsel

Bond Purchaser or Underwriter

Trustee (if applicable)

Project Finance Information

Provide an Estimate of the Uses of Funds:

Employment Plan

Confirmation

Electronic Communications

*Application Fee

Banner Health - $660,000,000

Non-Profits