Please complete as much of this form as possible before submitting the application. Items in bold are required. Also, please fax a copy of your latest completed balance sheet and income statement to 916-988-3931. LESSEE INFORMATION Legal Name of Lessee: Phone Number: Fax Number: Contact Person: Title: Email Address: Company Address: City: State/Province: Zip/Postal Code: Date municipal entity was established: Federal Tax ID: EQUIPMENT INFORMATION Total Cost of Equipment: $ Term (Years): Down Payment: $ Anticipated Delivery Date: Trade-in: $ Payment Mode: Monthly Quarterly Semi-Annual Annual Amount to Finance: $   Payments will be made in: Advance Arrears Is the equipment replacing existing "like" equipment? Yes   No If yes, how many years has the current equipment been in use? What is the reason for purchasing new equipment? Please describe the equipment being financed: Vendor web site address: Equipment to be financed is: New   Used Please describe in detail why the equipment is essential and the use it will provide: FUNDING INFORMATION Please specify which fund the rental payments will be made from: The appropriations for this project have been: Submitted   Approved Have you ever been in Default or Non-Appropriated on a Municipal Lease? Yes   No Will you borrow more or less than $10,000,000 in total new borrowing during this calendar year? More   Less Person signing documents is: Title: Person authorizing signatory to execute documents is: Title of person authorizing signatory: Clerk Secretary of the Board President of the Board Other Please fax a copy of your latest completed balance sheet and income statement to Leasource at 916-988-3931.

Please click here if you would rather use our Faxable Municipal Lease Application.