Form SBA FORM 2410 SBA FORM 2410 IMMEDIATE DISASTER ASSISTANCE PROGRAM (IDAP) BORROWER IN

OMB Control: 3245-0372

Expiration Date: 3/31/2011

IMMEDIATE DISASTER ASSISTANCE PROGRAM (IDAP)

BORROWER INFORMATION FORM

To be completed by the following and submitted to the Lender:

• For a sole proprietorship, the sole proprietor;

• For a partnership, all general partners and all limited partners owning 20% or more of the equity of the firm;

• For a corporation, all owners of 20% or more of the corporation and each officer and director;

• For limited liability companies (LLCs), all members owning 20% or more of the company, each officer, director, and managing member; and

• Any person hired by the business to manage day-to-day operations.

For clarification regarding any of the questions, the person completing this form should contact the SBA Participating Lender that will be processing the loan request.

DISASTER DECLARATION NO.: _______________________________________________________________________

APPLICANT BUSINESS NAME: _________________________________________________________________________

INDIVIDUAL NAME: ____________________________________ TITLE: _______________________________________

SOCIAL SECURITY NUMBER: __________________________ DATE OF BIRTH: _______________________________

PLACE OF BIRTH (City & State or Foreign Country): ________________________________________________________

ALL QUESTIONS MUST BE ANSWERED

(1) Are you presently under indictment, on parole or probation? Yes  No 

(2) Have you ever been charged with or arrested for any criminal offense other than a minor motor vehicle

violation (including offenses which have been dismissed, discharged, or not prosecuted) ? Yes  No 

(3) Have you ever been convicted, placed on pretrial diversion, or placed on any form of probation,

including adjudication withheld pending probation, for any criminal offense other than a minor motor

vehicle violation? Yes  No 

(4) Has any other application for an IDAP Loan to the applicant business for the Declared Disaster been

submitted by a lender to SBA? Yes  No 

(5) If you are at least a 50% or more owner of the applicant business, are you more than 60 days

delinquent on any obligation to pay child support arising under an administrative order, court

order, repayment agreement between the holder and a custodial parent, or repayment agreement

between the holder and a state agency providing child support enforcement services? Yes  No 

(6) Have you paid, or committed to pay, a fee to a third party, referral agent or broker to assist in the preparation of the loan application or application materials other than an application fee of up to $250 to the lender? Yes  No 

If ‘YES’ to any above question, this application may not be submitted under the IDAP Loan Program. Your business may still be eligible for a direct disaster loan from SBA under the SBA Disaster Loan Program. Please contact the SBA Disaster Assistance Customer Service Center at (800) 659-2955 or disastercustomerservice@sba.gov for assistance.

(7) Did you (or will you) pay the lender an application fee? Yes  No 

If answer is “Yes,” enter the amount here: _________________.

(8) Has your business applied to SBA for a direct Disaster Loan for the Declared Disaster? Yes  No 

If “Yes,” list application number: ___________________________________________

(9)Are you a U.S. Citizen? Yes  No 

If “No,” are you a Lawful Permanent resident alien? Not Applicable  Yes  No 

Complete: Alien Registration Number ____________________

Copy of your alien registration document is attached to this application. Not Applicable  Yes  No 

(10) Is your business a franchise? Yes  No 

(11) Do you, the applicant business, its affiliates, or any business owned or controlled by you, the applicant business or any of its Associates have any Federal obligations, including but not limited to any Federal loans, contracts, grants, student loans or taxes? Yes  No 

If “Yes,” are any of the Federal obligations currently delinquent? Not Applicable  Yes  No 

Is there a judgment lien for a Federal debt against the business property? Not Applicable  Yes  No 

(12) Have you, the applicant business, its affiliates, or any businesses owned or controlled by you, the applicant business

or any of its Associates had a previous SBA-guaranteed or disaster loan? Yes  No 

If “Yes,” is the loan either current or paid in full? Not Applicable  Yes  No 

(13) Was the applicant business established before the date of the Declared Disaster? Yes  No 

(14) How many employees did the applicant business have on the date of the Declared Disaster? _____________

(15) Has the applicant business had a substantial change in ownership (more than 50 percent) after the date of the Declared Disaster? Yes  No 

If “Yes,” did a contract of sale exist prior to the Declared Disaster? Yes  No 

(16)  IDAP Loan proceeds must be used to repair physical damage caused by the Declared Disaster within the Declared Disaster Area and/or to address Substantial Economic Injury resulting from the Declared Disaster.  (Your answers to the questions below will allow your Lender to determine whether you are eligible for an IDAP Loan.)

(a) Did the applicant business have Physical Damage that was caused by the Declared Disaster within the Declared Disaster Area?  Yes ...No 

If “Yes,” answer the following questions:

• Provide your best estimate of the cost to repair or replace your damaged property below:

                              Real Property damage:                                              $ ____________

                              Business Personal Property damage

(inventory, machinery, vehicles, etc.): $ ____________

• List damaged property address(es) below:

Number, Street, and/or Post Office Box	City	County	State	Zip Code	Owned or Leased?

(b) Has your business suffered Substantial Economic Injury as a result of the Declared Disaster? (Substantial Economic Injury means that your business is unable to meet its obligations as they mature or pay its ordinary and necessary operating expenses.)     Yes …No 

If “Yes,” answer the following questions:

• When do you anticipate that the applicant business will return to normal operations? (Mo/Yr)_____________

• Provide an estimate of the amount of working capital necessary to carry your business until resumption of normal operations and for expenditures necessary to alleviate the economic injury.                   $ _______________

• List the physical address where the economic injury occurred below:

Number, Street, and/or Post Office Box

City

County

State

Zip Code

(17) If your business has any type of hazard, flood, or business operation disruption insurance, complete the following for each insurance policy:

Type of Insurance	Name of Insurance Company	Agent’s Name and Phone #	Policy No.	Claim No.	Status	Policy Limit	Deductible

(18) Have you received any compensation for your disaster losses from other recoveries, including insurance, grants, reimbursements, claims, settlements, gifts, condemnation awards or salvage? Yes  No 

If “YES,” list all compensation received below:

  

Amount of Compensation	Source of Compensation

(19) Has your business relocated or is your business relocating outside the business area in which the Declared Disaster occurred? Yes  No 

(20) Is your business located in a Special Flood Hazard Area (SFHA), as designated by the Federal Emergency Management Agency (FEMA)? Yes  No 

If “Yes,” answer the following questions:

Have you maintained any required flood insurance on the business property? Yes  No 

Is the community in which your business is located a non-participating community or a community under sanction? Yes  No 

(21) Is your business located in a Coastal Barrier Resource Area (COBRA)? Yes  No 

(22) Was your business newly constructed or substantially improved on or after February 9, 1989, and currently located seaward of mean high tide or entirely in or over water? Yes  No 

(23) Is your business a sole proprietorship, unincorporated association, partnership or limited liability

company?......................................................................................................................................... Yes  No 

If “Yes,” does a Member of Congress (or a household member) have an ownership interest in the

business? Not Applicable  Yes  No 

SBA may not provide financial assistance to an applicant where there is any appearance of a conflict of interest on the part of SBA or the Lender. Please answer the following questions. If “false” is checked, the application may not be submitted under this program.

• No SBA employee, or the household member * of an SBA employee, is a sole proprietor, partner, officer, director, or stockholder with a 10 percent or more interest, of the Applicant. [13 CFR 105.204] True____ False_____

• No former SBA employee, who has been separated from SBA for less than one year prior to the request for financial assistance, is an employee, owner, partner, attorney, agent, owner of stock, officer, director, creditor or debtor of the Applicant. [13 CFR 105.203] True____ False_____

• No member of Congress, or an appointed official or employee of the legislative or judicial branch of the Federal Government, is a sole proprietor, general partner, officer, director, or stockholder with a 10 percent or more interest, or household member of such individual, of the Applicant. [13 CFR 105.301(c)] True____ False_____

• No Government employee having a grade of at least GS-13 or higher is a sole proprietor, general partner, officer, director, or stockholder with a 10 percent or more interest, or a household member of such individual, of the Applicant. [13 CFR 105.302(a).]

True_____ False_____

• No member or employee of a Small Business Advisory Council or a SCORE volunteer is a sole proprietor, general partner, officer, director, or stockholder with a 10 percent or more interest, or a household member of such individual, of the Applicant. [13 CFR 105.302(a).] True____ False_____

* A “household member” of an SBA employee includes: a) the spouse of the SBA employee; b) the minor children of said individual; and c) the blood relatives of the employee, and the blood relatives of the employee’s spouse who reside in the same place of abode as the employee.

Please read the following restrictions regarding use of federal financial assistance programs. If you understand them fully and agree to them, sign your name at the end of this document.

SBA is required to withhold or limit financial assistance, to impose special conditions on approved loans, to provide special notices to applicants or borrowers and to require special reports and data from borrowers in order to comply with legislation passed by the Congress and Executive Orders issued by the President and by the provisions of various inter-agency agreements. SBA has issued regulations and procedures that implement these laws and executive orders. These are contained in Parts 112, 113, and 117 of Title 13 of the Code of Federal Regulations and in Standard Operating Procedures (SOPs).

Freedom of Information Act (5 U.S.C. 552)

This law provides, with some exceptions, that SBA must supply information reflected in agency files and records to a person requesting it. Information about approved loans that will be automatically released includes, among other things, statistics on our loan programs (individual borrowers are not identified in the statistics) and other information such as the names of the borrowers (and their officers, directors, stockholders or partners), the collateral pledged to secure the loan, the amount of the loan, its purpose in general terms and the maturity. Proprietary data on a borrower would not routinely be made available to third parties. All requests under this Act are to be addressed to the nearest SBA office and be identified as a Freedom of Information request.

Privacy Act (5 U.S.C. 552a)

A person can request to see or get copies of any personal information that SBA has in his or her file when that file is retrievable by individual identifiers such as name or social security numbers. Requests for information about another party may be denied unless SBA has the written permission of the individual to release the information to the requestor or unless the information is subject to disclosure under the Freedom of Information Act.

Under the provisions of the Privacy Act, you are not required to provide your social security number. Failure to provide your social security number may not affect any right, benefit or privilege to which you are entitled. Disclosures of name and other personal identifiers are, however, required for a benefit, as SBA requires an individual seeking assistance from SBA to provide it with sufficient information for it to make a character determination. In determining whether an individual is of good character, SBA considers the person’s integrity, candor, and disposition toward criminal actions. Additionally, SBA is specifically authorized to verify your criminal history, or lack thereof, pursuant to section 7(a)(1)(B), 15 USC Section 636(a)(1)(B). Further, for all forms of assistance, SBA is authorized to make all investigations necessary to ensure that a person has not engaged in acts that violate or will violate the Act or the Small Business Investment Act, 15 USC Sections 634(b)(11) and 687(b)(a). For these purposes, you are asked to voluntarily provide your social security number to assist SBA in making a character determination and to distinguish you from other individuals with the same or similar name or other personal identifier.

The Privacy Act authorizes SBA to make certain “routine uses” of information protected by that Act. One such routine use is the disclosure of information maintained in SBA’s investigative files system of records when this information indicates a violation or potential violation of law, whether civil, criminal, or administrative in nature. Specifically, SBA may refer the information to the appropriate agency, whether Federal, State, local or foreign, charged with responsibility for or otherwise involved in investigation, prosecution, enforcement or prevention of such violations. Another routine use is disclosure to other Federal agencies conducting background checks; only to the extent the information is relevant to the requesting agencies’ function. See, 74 F.R. 14890 (2009), and as amended from time to time, for additional background and other routine uses.

Flood Disaster Protection Act (42 U.S.C. 4011) -- Regulations have been issued by the Federal Insurance Administration (FIA) and by SBA implementing this Act and its amendments. These regulations prohibit SBA from making certain loans in an FIA designated floodplain unless Federal Flood insurance is purchased as a condition of the loan. Failure to maintain the required level of flood insurance makes the applicant ineligible for any financial assistance from SBA, including disaster assistance.

Executive Orders -- Floodplain Management and Wetland Protection (42 F.R. 26951 and 42 F.R. 26961) -- SBA discourages settlement in or development of a floodplain or a wetland. This statement is to notify all SBA loan applicants that such actions are hazardous to both life and property and should be avoided. The additional cost of flood preventive construction must be considered in addition to the possible loss of all assets and investments due to a future flood.

Occupational Safety and Health Act (15 U.S.C. 651 et seq.) -- This legislation authorizes the Occupational Safety and Health Administration in the Department of Labor to require businesses to modify facilities and procedures to protect employees or pay penalty fees. Businesses can be forced to cease operations or be prevented from starting operations in a new facility. Therefore, SBA may require additional information from an applicant to determine whether the business will be in compliance with OSHA regulations and allowed to operate its facility after the loan is approved and disbursed. Signing this form as an applicant is certification that the OSHA requirements that apply to the applicant business have been determined and that the applicant, to the best of its knowledge, is in compliance. Furthermore, applicant certifies that it will remain in compliance during the life of the loan.

Civil Rights Legislation -- All businesses receiving SBA financial assistance must agree not to discriminate in any business practice, including employment practices and services to the public on the basis of categories cited in 13 C.F.R., Parts 112, 113, and 117 of SBA Regulations. This includes making their goods and services available to handicapped clients or customers. All business borrowers will be required to display the "Equal Employment Opportunity Poster" prescribed by SBA.

Equal Credit Opportunity Act (15 U.S.C. 1691) -- The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status or age (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant's income derives from any public assistance program, or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act.

Executive Order 11738 -- Environmental Protection (38 F.R. 251621) -- The Executive Order charges SBA with administering its loan programs in a manner that will result in effective enforcement of the Clean Air Act, the Federal Water Pollution Act and other environment protection legislation.

Debt Collection Act of 1982, Deficit Reduction Act of 1984 (31 U.S.C. 3701 et seq. and other titles) -- These laws require SBA to collect aggressively any loan payments which become delinquent. SBA must obtain your taxpayer identification number when you apply for a loan. If you receive a loan, and do not make payments as they come due, SBA may take one or more of the following actions: (1) report the status of your loan(s) to credit bureaus, (2) hire a collection agency to collect your loan, (3) offset your income tax refund or other amounts due to you from the Federal Government, (4) suspend or debar you or your company from doing business with the Federal Government, (5) refer your loan to the Department of Justice or other attorneys for litigation, or (6) foreclose on collateral or take other action permitted in the loan instruments.

Immigration Reform and Control Act of 1986 (Pub. L. 99-603) -- If you are an alien who was in this country illegally since before January 1, 1982, you may have been granted lawful temporary resident status by the United States Immigration and Naturalization Service pursuant to the Immigration Reform and Control Act of 1986. For five years from the date you are granted such status, you are not eligible for financial assistance from the SBA in the form of a loan guaranty under Section 7(a) of the Small Business Act unless you are disabled or a Cuban or Haitian entrant. When you sign this document, you are making the certification that the Immigration Reform and Control Act of 1986 does not apply to you, or if it does apply, more than five years have elapsed since you have been granted lawful temporary resident status pursuant to such 1986 legislation.

Lead-based Paint Poisoning Prevention Act (42 U.S.C. 4821 et seq.) -- Borrowers using SBA funds for the construction or rehabilitation of a residential structure are prohibited from using lead-based paint (as defined in SBA regulations on all interior surfaces, whether accessible or not, and exterior surfaces, such as stairs, decks, porches, railing, window and doors, which are readily accessible to children under 7 years of age. A "residential structure" is any home, apartment, hotel, motel, orphanage, boarding school, dormitory, day care center, extended care facility, college or other school housing, hospital, group practice or community facility and all other residential or institutions structure where persons reside.

Right to Financial Privacy Act of 1978 (12 U.S.C. 3401) -- This is notice to you as required by the Right to Financial Privacy Act of 1978, of SBA's access rights to financial records held by financial institutions that are or have been doing business with you or your business, including any financial institutions participating in a loan or loan guaranty. The law provides that SBA shall have a right of access to your financial records in connection with its consideration or administration of assistance to you in the form of a Government guaranteed loan. SBA is required to provide a certificate of its compliance with the Act to a financial institution in connection with its first request for access to your financial records, after which no further certification is required for subsequent accesses. The law also provides that SBA's access rights continue for the term of any approved loan guaranty agreement. No further notice to you of SBA's access rights is required during the term of any such agreement. The law also authorizes SBA to transfer to another Government authority any financial records included in a application for a loan, or concerning an approved loan or loan guarantee, as necessary to process, service or foreclose on a loan guaranty or collect on a defaulted loan guaranty.

I have read the items above and I understand them. I agree to comply, whenever applicable, with the hazard insurance, lead-based paint, civil rights or other limitations in this notice. I agree that all SBA loan proceeds will be used only for business related disaster recovery purposes as specified in the loan application and, to the extent feasible, to purchase only American-made equipment and products. I authorize the SBA Office of Inspector General to request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for programs authorized by the Small Business Act, as amended. SBA has my permission, as required by the Privacy Act, to release information to Federal, state, local or private disaster relief services (American Red Cross, Salvation Army, Mennonite Disaster Services, etc.) and to the lender. I authorize my insurance company to release to SBA and/or the Lender all records and information necessary to process this application.

I certify that the information provided in this application and supporting documents is true and accurate. I realize that the penalty for knowingly making a false statement or overvaluing security to obtain a guaranteed loan from SBA is that I may be fined up to $250,000 and/or be put in jail for up to 5 years under 18 USC §1001 and if submitted to a Federally insured institution, I may be fined up to $1,000,000 and/or be put in jail for up to 20 years under 18 USC §1014.

____________________________ _____________________

Signature Date

____________________________

Print Name

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 10 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 2410 (4/2011) 10