SBA Form 994H Default Report Claim for Reinbursement

OMB Control No: 3245-0007
Expiration Date: XX-XX-XXXX

U.S. SMALL BUSINESS ADMINISTRATION
DEFAULT REPORT, CLAIM FOR REIMBURSEMENT, REPORT OF RECOVERIES
AND RECORD OF ADMINISTRATIVE ACTION
(See page 3 for instructions)
Any intentionally false statement or willful misrepresentation in connection with a claim for payment pursuant to a Guarantee Agreement is a
violation of Federal law, subject to criminal and civil prosecution under 18 USC Sections 287, 371, 1001, 15 USC Section 645 and 31 USC Section
3729 carrying possible fines and/or imprisonment.
A. SBG IDENTIFICATION SUMMARY
SBG NUMBER:
SURETY NAME:
BOND NUMBER:
CLAIM NUMBER:

CONTRACTOR’S NAME:
990 DATE: (see instructions)
CONTRACT AMOUNT $:
OBLIGEE:
PROJECT:

DEFAULT STATUS CODE:
 01 — Active
 02 — Closed-No Loss
 03 — Closed-Subrogation
 04 — Closed-Final
 05 — Closed Settled

BOND TYPE:
 Payment
 Performance
 Bid

DEFAULT REASON CODE: (see instructions)

DEFAULT DATE:
LAST STATUS REPORT DATE:
 No Change from previous Report
 Status Update Included: (Describe below, current status and default
completion plans)
SURETY RESERVE AMOUNT $:

CLOSE DATE: (SBA USE ONLY)

SBA’S RESERVE AMOUNT $:

B. SUBROGATION ACTIVITY (Explain in Section C., below, or attach a separate sheet if, necessary.)
 Litigation Pending
 Payments being made

 Settled for $:
 None – Bankrupt/Defunct

 No Change from last report
 Approval requested to Close Final
 Firm Collateral Held $:

Other anticipated recovery from salvage, indemnities, etc. $:
C. EXPLANATIONS, COMMENTS, ADMINISTRATIVE ACTIONS (Attach additional sheet if warranted.)

D. SBA/SBG CLAIM PAYMENT RECOMMENDATION, REVIEW, APPROVAL, AND AMOUNT OF CLAIM APPROVED
(SBA USE ONLY)

THIS REQUEST IS HEREBY APPROVED FOR PAYMENT IN ACCORDANCE WITH SBA REGULATIONS.
AMOUNT REQUESTED $:
AMOUNT APPROVED $:
EFFECTIVE DATE (SBA Received):
Recommended By (Signature/Title/Date)

Reviewer (Initials/Date)

SBA Form 994H (03/19) Previous Editions are Obsolete

2nd Reviewer (Initials/Date)

Approving Official (Signature/Title/Date)

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E. ITEMIZATION OF SURETY LOSS (See Instructions; Loss Class Codes: L=Loss; E=Expense; TA=Trust Account Deposit)
DRAFT DATE

DRAFT NUMBER

PAYEE

AMOUNT

LOSS CLASS

TOTAL $:
F. ITEMIZED SURETY RECOVERY (See Instructions; Recovery Class Codes: I=Indemnity; C=Contract Funds)
DATE

SOURCE

RECOVERED AMOUNT

TOTAL $:
G. SUMMARY OF CLAIM FOR REIMBURSEMENT (See Instructions)
Total of Loss Disbursements (Itemized Above)

$

Total of Loss Disbursements Previously Reported

$
TOTAL LOSS DISBURSEMENTS

Recovery (Itemized Above)

$

Recovery Previously Reported

$

Undisbursed Trust Account Balance (see instructions page)

$
TOTAL OFFSETS

$

-$

Surety Net Loss (Total Loss Disbursements Less Total Offsets)

$

Less Deductible Amount (see instructions page)

-$

SBA ( )% Share of Surety’s Reimbursable Loss

$

Less Prior Total SBA Payments

-$

TOTAL DUE AND REQUESTED BY SURETY 
H. CERTIFICATION

RECOVERY CLASS

or TOTAL DUE AND SUBMITTED TO SBA 

I, the undersigned being duly designated, hereby certify that this default report and/or itemization and summary of payments and
recoveries received upon bonds issued in conjunction with the U.S. Small Business Administration’s Surety Bond Guarantee Program
is true and correct to the best my knowledge, information and belief. I further certify that all payments made and recoveries
received are substantiated by payroll sheets, copies of Surety’s drafts, claimants invoices, assignments and releases (where
applicable), recovery instruments, etc., and that such substantiating documents are retained in this office, our agent’s office, or in
the office of our claim account trustee. I further certify that the Surety has complied with all SBA Surety Bond Guarantee Program
regulations in 13 CFR Part 115 and all SBA program requirements.
NAME OF SURETY

(Area Code/Phone No.)

SBA Form 994H (03/19) Previous Editions are Obsolete

SURETY CERTIFYING OFFICIAL’S SIGNATURE, TITLE, AND DATE

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INSTRUCTIONS AND CLARIFICATION
OF SELECTED FORM 994H ITEMS
General
1.

This form may be used to report the default of an SBG contractor, claim for reimbursement, recovery, as well as for periodic
status reporting in accordance with the terms of SBA’s Surety Bond Guarantee Agreement. If a different format is used, all
information requested on 994H Form must be provided.
2. This form is to be completed by Prior Approval Sureties. This form may be completed electronically in the Capital Access
Financial System (CAFS) located at https://www.sba.gov/partners/surety-bond-partners-agents/operate-surety-partner-oragent. If the form is prepared electronically, the completed form must be downloaded, printed and signed and then uploaded
into CAFS. Alternatively, If CAFS is unavailable a paper copy of the form is available on the Office of Surety Guarantees (OSG)
website at https://www.sba.gov/partners/surety-bond-partners-agents/operate-surety-partner-or-agent where it may be
printed, completed, signed and mailed to the OSG office at 409 3rd Street, S.W. Suite 8600 Washington, D.C. 20416.
3. A separate SBA Form 994H must be used for each bond in default/claim status. An additional sheet/letter may be attached for
more detailed reporting.
4. If this is an initial default/claim notice:
i. Provide a detailed report including the percentage of completion, remaining contract funds, methods of selecting
completion contractor, description of how claim situation arose, present condition, surety’s plans for resolution and
salvage, anticipated loss.
5. Submitting the requested information is voluntary, but failure to do so could affect processing of your claim.
− “990 Date” is the date SBA Form 990, “Surety Bond Guarantee Agreement,” was signed by SBA Official.
Section A.
−

Section E.

Section F.
Section G.

DEFAULT REASON CODES:

CODE
CODE
1. Underbidding
14. General’s subcontractor in default
2. Weather/natural disasters
15. Sub’s General in default
3. Shortage in critical materials/
16. Possible sub-busting on part of general
Delays in receiving same
17. IRS lien
4. Alleged embezzlement
18. Sub’s General behind Schedule
5. Financial mismanagement
19. Unforeseen physical obstacle
6. Incompetence/poor workmanship
20. Shortage of labor
7. Union strike/labor trouble
21. Principal fails to appear at job site
8. Illness or death of key employee
to begin work
9. Walked off job
22. Fire damage
10. Dispute with obligee
23. Materialman lien
11. Possible fraudulent operation
24. Labor lien
on part of principal
25. Principal failed to sign contract
12. Despondency
26. Surety did not issue final bond
13. Co-mingling of funds
27. Other
− List all loss items as well as funds deposited to a trust account. A separate accounting must accompany any request for
reimbursement of loss incurred via a trust account. Such accounting must provide the source of all deposits to the account,
and the disposition of all funds from the account (by date, draft number, payee and amount). Any balance remaining in the
account or any amounts not accounted for as expenditures comprise the trust account balance and are to be included in
Section G. as “Undisbursed Trust Account Balance.”
− List all recovery items received by the Surety. Also, list as recovery, all trust account remaining balances returned by the
trustee.
− The “Undisbursed Trust Account Balance” is reduced to zero when the remaining balances are returned by the trustee. See
instructions for Section E., above.
− The “Total of Loss Disbursements” is the total amount from Section E., “Itemization of Surety Loss.”
− The “Total Loss Disbursements Previously Reported” is the combined total of loss disbursements itemized and previously
reported.
− The “Deductible Amount” is 80% of the Premium amount up to $500 for Guarantee Agreements written on/after April 21,
1976.

PLEASE NOTE: The estimated burden for completing this form is 15 minutes.. You are not required to respond to any collection of information
unless it displays a currently valid OMB Control number (3245-0007). Comments on the burden should be sent to U.S. Small Business
Administration, Records Management Division, 409 3rd St., SW, Washington DC 20416 and Desk Officer for the Small Business Administration,
Office of Management and Budget, New Executive Office Building, Room 10202 Washington, DC 20503. PLEASE DO NOT SEND COMPLETED FORMS
TO OMB.

SBA Form 994H (03/19) Previous Editions are Obsolete

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