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WEZESHA FUND FORM

The document is an application form for the Kilifi County Micro Finance (Wezesha) Fund, requiring detailed information from applicants including personal, business, financial, and guarantor details. It outlines the necessary attachments and declarations needed for the application process, as well as the terms and conditions for loan repayment. Additionally, it includes sections for official use, recommendations, and a checklist of required documents.

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PRICE JOHN
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133 views

WEZESHA FUND FORM

The document is an application form for the Kilifi County Micro Finance (Wezesha) Fund, requiring detailed information from applicants including personal, business, financial, and guarantor details. It outlines the necessary attachments and declarations needed for the application process, as well as the terms and conditions for loan repayment. Additionally, it includes sections for official use, recommendations, and a checklist of required documents.

Uploaded by

PRICE JOHN
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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COUNTY GOVERNMENT OF KILIFI

KILIFI COUNTY MICRO FINANCE (WEZESHA) FUND

APPLICATION FORM
A) APPLICANT’S INFORMATION AND LOCATION

APPLICANTS DETAILS (as appears on ID, passport or certificate of registration(attach copy)


First Name Middle Name Last Name

Position

I. GROUP/COOPERATIVE/SOLE PROPRIATOR/ COMPANY


NAME_________________________________________
II. REG NO._______________________ Date of Registration _____________
III. County_____________________________Sub-County____________________
IV. Ward________________________________Location_______________________
V. Physical Address ______________________Nearest Landmark_______________
VI. Plot Number___________________
NB: Attach Copy of National ID card for all members & Passport photos for officials
GROUP MEMBERSHIP
Gender 18 years and above Persons with Disability
Male
Female
Total

PAMOJA TUJENGE UCHUMI WA KILIFI Page 1


B) BUSINESS DETAILS
i. Category of business Start –up Existing
ii. Type of Business_______________________________________________________________
iii. Briefly describe your products/service_____________________________________________
______________________________________________________________________________
______________________________________________________________________________
iv. Age of Business________________ Business Location______________
v. Nearest Landmark _______________________________Plot Number__________________
vi. License/Registration No. _____________ No. of employees __________________

BUSINESS FINANCIAL INFORMATION


NO MONTHLY BUSINESS AMOUNT MONTHLY BUSINESS AMOUNT
INCOME EXPENSES
1
2
3
4
TOTAL INCOME TOTAL EXPENSES

C) BANKING AND CREDIT HISTORY


i. Name of group/Co-operative/Business Bank Account________________________
ii. Account number ________________ Branch Name __________________
iii. When did you open your group Bank /Co-operative Account? ______________________
iv. Have you borrowed from any financial institution? Yes No
v. If yes, Name the lender / source of funds __________________
vi. How much________________________________
vii. Has the Loan been fully paid? Yes No
viii. If No why? __________________________________________________________________
ix. Do you proprietor/Group Members/Directors with outstanding loan balance? Yes
No

PAMOJA TUJENGE UCHUMI WA KILIFI Page 2


x. If YES, indicate the names of members below and outstanding amount

No Names Financial Date Amount Outstanding Duration


institution applied borrowed loan
balance
1
2
3
4
5
6
7
8

NB: Attach current Bank Statement for the last three months

D) INVESTMENT PLAN/LOAN PURPOSE

Amount applied for Kshs _________________

Briefly explain how the amount applied for will be utilized


Use the table below as a guide.
Amount Usage /Items

Total

PAMOJA TUJENGE UCHUMI WA KILIFI Page 3


Briefly describe your vision and growth plan for the business in the next one year

DECLARATION
I/We, the undersigned hereby declare that:
a) We are the Directors/ Proprietor of,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
b) I/We certify this information is true and correct and authorize the Bank to:
i. Contact any source for confirmation.
ii. Share information of our credit history with Credit Reference Bureaus
iii. Confirm bank details with our bankers as and when necessary
c) I/We agree to be bound by the terms and conditions of this facility as stipulated in the loan
agreement.
d) I/We agree to obtain credit insurance cover from the insurance company procured by the
Bank
e) Administration fees charged will be 4% and 6 % depending on the loan amount disbursed.
f) I/We authorize the Bank to deduct any premiums payable towards such insurance cover and
Administration fee from loan granted.
g) I/We understand that this application will go through a vetting process and should our loan
be approved a loan account of the principle
amount requested will be created in the name of the Firm.
h) I/We agree that we are jointly and severally liable for repayment of loan in the event of
default and
i) I/We shall not be eligible for additional loans unless the amount in default has been cleared in
full.
j) The Bank shall not process incomplete/ defective application form, for which if any loss or
delay is caused to me/ us, I/We will not hold
the Bank liable for such loss or delay.

Signed by all borrowers


N NAMES ID NO TEL NO LOCATION SIGNATURE
O
1.
2.
3.
4.
5.
6.

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7.
8.
9.
10.
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

E) SECURITY

I certify that We possess the items listed below and will be used in the event of our default

of the funds advanced to us by the Kilifi County micro finance(Wezesha) Fund we shall

PAMOJA TUJENGE UCHUMI WA KILIFI Page 5


forego the said items by way of Public Auction.(Groups savings will act as security)

F) APPLICANT’S ATTACHABLE ASSETS

ITEMS DESCRIPTION SERIAL NO. AMOUNT

G) GROUP GUARANTEE AND COMMITMENT TO LOAN REPAYMENT


We, the undersigned, being the validly elected leaders of the group/co-operative/owners of
business entity, hereby commit the group/co-operatives/business individually and jointly to
the loan terms and conditions to repay in (…………….) (subject to a maximum of 36
months) equal monthly installments after one month grace period the loan amount
disbursed to us by Kilifi County Microfinance(Wezesha) Fund. We also declare and confirm
that the information provided is correct. We understand that your office reserves the right to
verify this information and will be disqualified if found to have provided incorrect
information that’s material to assessment of our application.

Signed by Officials
a) Chairperson/Director/Sole Proprietor
Name ___________________________________ ID NO._____________________________
Tel No.__________________________________ Signature.___________________________
b) Secretary
Name___________________________________ ID NO.____________________________
Tel No.__________________________________
Signature.___________________________

c) Treasurer
PAMOJA TUJENGE UCHUMI WA KILIFI Page 6
Name ___________________________________ ID No._____________________________
Tel No.__________________________________ Signature.___________________________

H) GUARANTOR’S DETAILS (1)


Name of Guarantor __________________________
R/Ship to applicant__________________________
Mobile No._______________________________
ID No.____________________________________
Attach copy of ID
Signature of Guarantor _____________________
Present Occupation __________________________
Present residence____________________________
Nearest Landmark__________________________
Monthly income
a. Employment income_____________________
b. Business income________________________
c. Other sources of income _________________

I) GUARANTOR’S DETAILS (2)


Name of Guarantor __________________________
R/Ship to applicant__________________________
Mobile No._______________________________
ID No.____________________________________
Attach copy of ID
Signature of Guarantor _____________________
Present Occupation __________________________
Present residence____________________________
Nearest Landmark__________________________
Monthly income
d. Employment income_____________________
e. Business income________________________
f. Other sources of income _________________
PAMOJA TUJENGE UCHUMI WA KILIFI Page 7
J) FOR OFFICIAL USE

Application No.

RECOMMENDATIONS FROM THE WARD REVOLVING FUND COMMITTEE

RECOMMENDED NOT RECOMMENDED

Reasons for Recommending/Not Recommending

______________________________________________________________________________

______________________________________________________________________________

Chairperson

Signature: ________________________ Date: ______________________


Secretary:
Signature: _________________________ Date: _______________________
Minute No.________________________ Date: _______________________
COUNTY SECRETARIAT RECOMMENDATIONS

We have validated and technically assessed the proposal. We recommend to the Bank as

follows:Recommended Deferred Rejected

Give reasons for Recommendation/Deferral/ Rejection:

Credit Officer……………………..Signed……………………….Date……………

Recommended by Fund Manager………………..Signed……………Date…………..

PAMOJA TUJENGE UCHUMI WA KILIFI Page 8


BANK SECTION

Loan disbursement/repayment information

Amount applied for Kshs: ………………….. Amount disbursed: Kshs ………………

Repayment period:……………………….

Repayment commencement month: Date:………….. Month:…………..

Year:…………….

Installment amount per month:………………………………

Confirmed

Bank official

Name ___________________________

ID No.____________________________________

Tel No.__________________________

Signature: _________________________________

Approved Deferred Rejected

Give reasons for Approval/Deferral/ Rejection:

PAMOJA TUJENGE UCHUMI WA KILIFI Page 9


CHECKLISTS

FOR OFFICIAL USE ONLY


Application form must be returned with the following documents
1. Dully filled application form
2. Photocopies of the National ID Card for all the members
3. Passport photos for the group officials
4. Original 3 months Certified bank statements (Current)
5. Minutes of the group resolving to borrow
6. Group Savings Records
7. Constitution of the group
8. Valid Certified copy of registration certificate from the Department of Social
Services
SOLE PROPRIETOR/COMPANY/COOPERATIVE
1.Dully filled application form
2. Photocopies of the National ID Proprietor/Directors/Guarantors
3. Passport photos for the Proprietor/Directors
4. Original 3 months Certified bank statements (Current)
5. Minutes of the Company Board of Directors resolving to borrow
6 .Single Business permit from Kilifi County
7.Business registration Certificate/Certificate of Incorporation
8.Pin Certificate-KRA for the Directors/Signatories and the company
9. Audited accounts/Business Records
10. Copy of Certificate of Borrowing Powers for cooperatives
11. List of attachable assets

PAMOJA TUJENGE UCHUMI WA KILIFI Page 10

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