SBA FORM 2276 Part Supplemental Information for Gulf Opportunity Pilot Loan

OMB Control No.: 3245-0355

Expiration Date:

MB Approval No.: 3245-0348

Effective Date: 02/19/2004

Expiration Date: 02/28/2007

Supplemental Information for Gulf Opportunity Pilot Loan Program

(to be completed by lender)

Small Business Borrower Name: ____________________________________________________________

 Sole Proprietorship Partnership Corporation  LLC  Other

Trade Name (dba):

(if no trade name, enter “NA”)

Borrower Contact:

Mr

Ms

First

MI

Last

Borrower Street:
Borrower City:			Borrower County:

Borrower State :	(2 letter abbrev.)	Borrower Zip Code:
Borrower Phone #

Borrower Tax ID #:

(if available)

#

Owners SS #:

1.

2.

Lender Name:

Lender ID #:

Loan Amount: $______________

SBA Guaranty % ________

Loan Term in # of Months:_________

Interest Rate:

Prime rate* = _______ + Spread ______ = Variable Interest Rate: _______ LIBOR (1 month) + 3.0% * = _______ + Spread ______ = Variable Interest Rate: ________ SBA Peg Rate * = _______ + Spread ______ = Variable Interest Rate: ________ Fixed Base Rate* = _______ + Spread ______ = Fixed Interest Rate: ________ *in effect on the first business day of the month as identified in a national financial newspaper or SBA publication

 Variable  Fixed

Exporter?

Yes

No

If yes, amount in export sales applicant has projected loan will support $___________

New Business (2 years or less)	Existing Business (more than 2 years old)	Change of Ownership***
All Outstanding SBA Loans: _________________________
Loan is Collateralized
Rural  Urban (business location)

NAICS Code: ________________

New Construction? If checked, amount: $_________________

# of employees prior to loan

# of jobs created because of loan

# of jobs retained because of loan

Franchise Franchise Name: ___________________________________

Veteran**		1=Non-Veteran; 2=Veteran-Other; 3=Service-Disabled Veteran; 4=Not Disclosed.
Patriot Express*		Codes on next page. Each eligible owner must be identified with one of these codes.
Gender**		M=Male; F=Female; N=Not Disclosed
Race**		1=American Indian or Alaska Native; 2=Asian; 3=Black or African-American; 4=Native Hawaiian or Pacific Islander; 5=White; X=Not Disclosed
Ethnicity**		H=Hispanic or Latino; N=Not Hispanic or Latino; Y=Not Disclosed
Owner #	% Owned *		Veteran	Patriot Exp.*	Gender	Race	Ethnicity	Please reference the above codes to complete this table for each 20% or greater owner of the applicant business. More than one race may be selected.

** The gender/race/ethnicity/veteran data is collected for statistical purposes only. Disclosure is voluntary and has no bearing on the credit decision.

Were any other SBA loans with maturities of more than 12 months made to the borrower in the last 90 days? If so, please complete for each loan	SBA Loan #	SBA Approval Date	Loan Amount	SBA Guaranty %	Term (in months)

SBA Form 2276 (Part B) (Revised 10-10) Page 1 of 3

Supplemental Information for Gulf Opportunity Pilot Loan Program

Borrower Name:

Use of Loan Proceeds	Amount (Total Dollars)
Purchase Land only	$
Purchase Land and Improvements	$
Purchase Improvements only	$
Construct a Building	$
Add an Addition to an Existing Building	$
Make Renovations to an Existing Building	$
Pay Off Interim Construction Loan	$
Pay Off Lender’s Interim Loan	$
Leasehold Improvements	$
Purchase Equipment	$
Purchase Furniture and Fixtures	$
Purchase Inventory	$
Pay Trade or Accounts Payable	$
Pay Notes Payable – not Same Institution Debt	$
Pay Notes Payable – Same Institution Debt	$
Purchase Business (Change of Ownership) – ***Complete Page 3	$
Refinance SBA Loan	$
Working Capital	$
SBA Guaranty Fee	$
Other – Explain _____________________________	$
Total	$

Revolving Line of Credit?

Yes

No

Eligible Permanent Business Address: (Complete if different from current business address.)	(Street number and name)	(City)
	(County/Parish)	(State/Zip Code)

Lender Contact:

Mr

Ms

First

MI

Last

Lender Contact Phone #:

Lender Contact Fax #:

SBA Form 2276 (Part B) (Revised 10/10) Page 2 of 3

***Complete the following for a Change of Ownership of the Business

	Total Dollar Amount
Total Amount Paid to Seller	$
Sources:
7(a) Loan	$
Seller Financing – Amt. on full standby for at least 2 yr. – Amount not on full standby	$
	$
Buyer’s Equity Contribution:  Cash Describe source: ____________________	$
 Borrowed	$
 Other Describe: ________________________	$
Assets Purchased: (Net Book Value except where indicated)
Accounts Receivable	$
Inventory	$
Real Estate	$ Check one: Book Value Appraised Value
Machinery and Equipment	$ Check one: Book Value Appraised Value
Furniture and Fixtures	$
Intangible Assets**	$
Other: Describe _____________________	$
**Breakdown of Intangible Assets (if available):
Covenant not to compete	$
Customer/client list	$
License (liquor, FCC, etc)	$
Franchise rights, patents, trademarks, etc.	$
Goodwill	$
Other: Describe _____________________	$

Complete the following when an Independent Business Valuation is required by SOP 50 10 5:

Appraiser’s Conclusion or Summary of Value: $________________________________________

Name of Business Appraiser (person): __________________________________ Fee: $____________

Check qualification(s) of the Appraiser:

• Accredited Senior Appraiser (ASA)

• Certified Business Appraiser (CBA)

• Accredited in Business Valuation (ABV)

• Certified Valuation Analyst (CVA)

• Accredited Valuation Analyst (AVA)

• Certified Public Accountant (CPA) that performs the business valuation in accordance with the “Statement on Standards for Valuation Services”

Will a business broker receive a commission from the sale of the business?  Yes  No

If yes: Name of Business Broker (person): _________________________ Commission: $____________

Address: _________________________________________________________________________

NOTE: According to the Paperwork Reduction Act, you are not required to respond to this collection of information unless it displays a currently valid OMB Control Number. The estimated burden for completing this form, including time for reviewing instructions, gathering data needed, and completing and reviewing the form is 15 minutes per response. Comments or questions on the burden estimates should be sent to U.S. Small Business Administration, Chief, AIB, 409 3rd St., SW, Washington DC 20416. PLEASE DO NOT SEND FORMS TO THIS ADDRESS.

SBA Form 2276 (Part B) (Revised 10/10) Page 3 of 3