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PART IV <br />APPLICATION FOR TAX-EXEMPT FINANCING <br />(Commercial, Industrial or Health Care) <br />1. APPLICANT <br />a. Susiness Name: <br />b. Susiness Address: <br />c. Susiness Form (corporation, partnership, sole proprietorship, etc.) : <br />d. Authorized Representative: <br />e. Principal contact person and telephone number: <br />2. PURPOSE OF REQUESTED FINANCING: <br />a. New Facility (describe) : <br />b. Expansion (describe) : <br />c. Refunding (describe) : <br />3. GIVE SRIEF DESCRIPTION OF NATURE OF SUSINESS, PRINCIPAL PRODUCTS, <br />ETC.: <br />4. ESTIMATED PROJECT COSTS: (Not required for refunding) <br />Land $ <br />Suilding <br />Equipment <br />Architectural, Engineering <br />Costs of Issuance <br />Capitalized Interest, <br />including discount <br />Other <br />Total Financing Requested $ <br />5. AMOUNT OF FINANCING REQUESTED: $ ( % of project costs) <br />SJB-193102v1 5 <br />SA285-04 <br />