Eib 84-01 Red Lined

OMB No.: 3048-003
Expiration Date: PENDING

U.S. SMALL BUSINESS ADMINISTRATION
and
EXPORT-IMPORT BANK OF THE UNITED STATES
JOINT APPLICATION FOR EXPORT WORKING CAPITAL GUARANTEE

APPLICATION INSTRUCTIONS
PART A. PRINCIPAL PARTIES
1. Borrower/Exporter. Complete this section with information on the individual or corporate borrower. Provide the
primary North American Industrial Classification System (NAICS) number of the borrower, rather than the product being
exported.
2. Borrower’s Management. Complete this section for each proprietor, partner, officer, director or other individual
owning 20% or more of the borrower. 100% of ownership must be shown. The following are considered “Associates” of
the borrower: a. for a sole proprietorship, the sole proprietor; b. for a partnership, all general partners and all limited
partners owning 20% or more of the equity of the firm; c. for a corporation, all owners of 20% or more of the
corporation and each officer and director; d. for limited liability companies (LLCs), all members owning 20% or more of
the company, each officer, director, and managing member; d. any person hired by the business to manage day-to-day
operations. All Associates must be shown.
3. Borrower’s Affiliate(s). Provide information about all of the Borrower’s Affiliates (whether applying for SBA or Ex-Im).
Affiliation exists when one individual or entity controls or has the power to control another or when a third party or
parties control or have the power to control both. SBA guidelines (which provide a definition also used by Ex-Im)
consider factors such as ownership, management previous relationship with or ties to another entity, and contractual
relationships when determining whether affiliation exists. The complete definition of affiliation is found at 13 CFR
121.103. (See also, 13 CFR 121.107 and 121.301.) An “Affiliate” includes, for example: (a) a parent company; (b)
subsidiaries and other companies that are owned or controlled by the borrower; (c) companies in which an officer,
director, general partner, managing member or party owning 20% or more is also an officer, director, general partner,
managing member or 20% or greater owner of the borrower; (d) companies or individuals with unexercised options to
own 50% or more of the borrower’s stock; and (e) companies that have entered into agreement to merge with the
borrower.
4. Personal and/or Corporate Guarantor(s). List all individuals and entities that will guarantee repayment of the loan.
The personal guarantee of the owner(s) is required in most cases.
5. Lender. Leave blank if you are applying for a Preliminary Commitment and a prospective lender has not been
identified.
PART B. INFORMATION ABOUT THE TRANSACTION
Provide type of loan requested, the loan amount, and term and answer all questions in Part B. (See also Checklist item 2
below.)
PART C. CERTIFICATIONS
This section must be signed by an authorized representative of the borrower, each guarantor, and, if this is a request for
a final commitment, the Lender. For SBA Applicants only—this section must be signed by each Associate of the
borrower (see above for definition) and each guarantor.
EIB-SBA Form 84-1, Revised 05/2015

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OMB No.: 3048-003
Expiration Date: PENDING
CHECKLIST OF INFORMATION TO BE ATTACHED
BACKGROUND

YES

N/A

TRANSACTION

YES

N/A

FINANCIAL INFORMATION

YES

N/A

YES

N/A

1. Brief resume of the principals and key employees; history of business; copy of business plan, if available; identify
whether sole proprietorship, general partnership, limited liability company (LLC), corporation and/or subchapter-S
corporation.
2. Explanation of use of proceeds and benefits of the loan guarantee, including details of the underlying
transaction(s) for which the loan is needed, including country(s) where the buyers are located.
3. Attach product literature. Ex-Im Bank applicants only: If applicable, attach description of items if they are
nuclear, military, environmental, on the U.S. Munitions Control List, or require an export license.
4. Copy of letter of credit and/or copy of buyer’s order/contract, if available.
5. Export credit insurance-related material (policy, application, buyer credit limit), if applicable.
6. Copy of export license, if required.
7. Business financial statements (Balance Sheet, Income Statement, statement of Cash Flows) for the last three
years, if applicable, supported by the most recent Federal income tax return for the business. SBA applicants only:
Also submit the last three years of signed Federal income tax returns for the business.
8. Current financial statement (interim) dated within 90 days (SBA Applicants only: 180 days) of the date of the
application filing.
9. Aging of accounts receivable and accounts payable, as of the same date as #8 above.
10. All Affiliated Companies – Business Financial Statements (Balance Sheet, Income Statement, Aging of Accounts
Receivable and Accounts Payable) for the last completed fiscal year end, as well as current statements no older
than 90 days (SBA Applicants only: 180 days) from the date of application filing. In addition, submit signed
Federal income tax returns for the last fiscal year end or an extension form if not filed after the due date.
Important Requirement – Submit a combined or consolidated financial statement for the current period as
well as the last fiscal year end (combining all affiliated companies), eliminating any inter-company transactions
(sales, receivables, payables, etc.).
11. Signed joint personal financial statement(s) of each major shareholder(s)/partner(s), owner(s), of the
company (with 20% or greater ownership, including assets and liabilities of both spouses) and their most recent
Federal income tax return (not required for venture capital partners).
12. Estimate of monthly cash flow for the terms of the loan, highlighting the proposed export transaction.
13. Description of type and value of proposed collateral to support the loan (company assets/export product, i.e.,
inventory, accounts receivable, other).
14. Attach credit memorandum prepared by the Lender. SBA applicants only: Also attach D&B Report and
Personal Credit Reports on Principals and Guarantors.
15. Ex-Im Bank applicants only: Nonrefundable $500 application fee for a Preliminary Commitment or
nonrefundable $100 application fee for a Final Commitment, whichever is applicable, by check or money order
made out to the Ex-Im Bank.
16. SBA applicants only: Copy of IRS Form 4506-T (original to be submitted to IRS by the Lender).
OTHER INFORMATION
17. SBA applicants only: If there is a “YES” response to Question e.2. or e.3. in Part C.2., submit a completed SBA
Form 912 with details furnished on a separate sheet, including dates, location, fines, sentences, whether
misdemeanor or felony, dates of parole/probation, unpaid fines or penalties, name(s) under which charged, and
any other pertinent information. NOTE: If there is a “YES” response to Question e.1. in Part C.2., the loan request
is ineligible for SBA assistance.
18. SBA applicants only: If the borrower used (or intends to use) a packager, broker, accountant, lawyer, etc. to
assist in (a) preparing the loan application or any related materials and/or (b) referring the loan to the lender, a
SBA Form 159 7(a) will need to be completed by the borrower and the lender and submitted.
19. SBA applicants only: If the lender is processing this loan under its PLP-EWCP delegated authority, lender must
submit SBA Form 1920.

EIB-SBA Form 84-1, Revised 05/2015

2.

OMB No.: 3048-003
Expiration Date: PENDING
(SBA Use Only)

U.S. SMALL BUSINESS ADMINISTRATION

Date Received:

EXPORT-IMPORT BANK OF THE UNITED STATES

C.I.D. No.:

(Ex-Im Bank Use Only)
Date Received:

JOINT APPLICATION FOR
EXPORT WORKING CAPITAL GUARANTEE

Intermediary:

PART A. PRINCIPAL PARTIES
Please check the
appropriate answer:
Dba/

1. Borrower/Exporter
Company Name
Telephone No.

Fax No.

New to Ex-Im Bank?
New to SBA?

D&B No.
E-mail Address

Address (No P.O. Boxes)

City

Gross Annual
Sales Last Year:

No. of Full-Time
Employees:

State

Primary North American Industrial
Classification System (NAICS) No.:

Zip+4

“Small Business Concern” as
described in SBA Guidelines:
Yes

*Is the Borrower a minorityowned business?
Yes

No

*A women-owned business?

Not Disclosed

Yes

No

No
No

Federal ID No.

Name and Title of Contact Person
County of Business

Yes
Yes
Date Business
Established

No

*A Veteran-owned business?

Not Disclosed

Yes

No

Not Disclosed

2. Borrower’s Management (Proprietors, partners, officers, directors and holders of all outstanding
stock or other ownership interests – 100% of ownership must be shown. Include anyone who was a
principal within the last six months.) Attach separate sheet of paper if necessary.
1) Name
Title/Management Position

EIB-SBA Form 84-1, Revised 05/2015

% owned
Complete Address

Social Security No.

*Gender
M

F

3.

OMB No.: 3048-003
Expiration Date: PENDING
Date of Birthλ

Place of Birthλ

Raceλ* (one or more boxes may be selected.)
American Indian or Alaskan Native

E-mail Address

λ

Asian

This information
is for SBA only.

λ

Black or African American

Native Hawaiian or Pacific Islander

Ethnicity *:

Hispanic or Latino

Military Service Statusλ* (choose one):

Non-Veteran

Veteran

2) Name

% owned

Title/Management Position
Date of Birthλ

Service Disabled Veteran

Social Security No.

λ

Asian

This information
is for SBA only.

λ

Hispanic or Latino

Military Service Statusλ* (choose one):

Non-Veteran

Veteran

3) Name

% owned

Title/Management Position

Not Hispanic or Latino

Social Security No.

*Gender
M

Complete Address

Place of Birthλ

F

Raceλ* (one or more boxes may be selected.)

λ

Asian

This information
is for SBA only.

Military Service Statusλ* (choose one):

White

Service Disabled Veteran

American Indian or Alaskan Native

E-mail Address

F

Black or African American

Native Hawaiian or Pacific Islander

Ethnicity *:

Date of Birthλ

*Gender
M

Raceλ* (one or more boxes may be selected.)
American Indian or Alaskan Native

E-mail Address

Not Hispanic or Latino

Complete Address

Place of Birthλ

White

λ

Black or African American

Native Hawaiian or Pacific Islander

Ethnicity *:

Hispanic or Latino

Non-Veteran

Veteran

White

Not Hispanic or Latino

Service Disabled Veteran

* The gender/race/ethnicity/veteran data is collected for program reporting purposes only. It has no bearing on credit
decision. Disclosure is voluntary.

3. Borrower’s Affiliate(s) If more than one affiliate, please attach separate sheet of paper.
Company Name
Telephone No.

Fax No.

D&B No.

Name and Title of Contact Person
Street Address
(No P.O. Boxes)

E-mail Address

County of Business

Number of Employees for each affiliate

EIB-SBA Form 84-1, Revised 05/2015

Federal ID No.

City

State

Zip+4

Describe Nature of Affiliation

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Expiration Date: PENDING
4. Personal and/or Corporate Guarantor(s) If more than one guarantor, please attach separate sheet of
paper.

Name (last, first middle initial)

Social Security No.

Federal ID No. (if applicable)

Date of Birthλ

Place of Birthλ

Telephone No.

Street Address

County of Business

E-mail Address

City

Fax No.
State
Zip + 4

5. Lender
Lender Name

Federal ID No.

New to Ex-Im?

Yes

No

New to SBA?

Yes

No

(If new to Ex-Im or SBA, submit annual report)

Name and Title of Contact Person (last, first middle initial)
Street Address
State

Telephone No.

Fax No.

City
Zip +4

E-mail Address

EIB-SBA Form 84-1, Revised 05/2015

5.

OMB No.: 3048-003
Expiration Date: PENDING

PART B. INFORMATION ABOUT THIS TRANSACTION
1. Loan Information
Loan Amount:

Term of Loan:

Revolving
Not Revolving
Asset-based
Transaction-based
Standby L/C
L/C Amt:

Ex-Im
Bank
Only

Interest Rate to be Charged:
Lender Interest Rate % per Annum

Revolving
Transaction(s) Specific
Transaction Specific
Revolving
Fast Track
Supply Chain

Base Rate:

SBA Only

Yes

No

Ex-Im
Bank Only

If yes, amount existing loan

Yes

If yes, amount currently outstanding

No

Other Fees or Charges
(please enter the type and amount below):

Conversion of Preliminary
Commitment?

If Interest Rate is to be Variable
Adjustment Period:

1 year

Other (specify):
Renewal?

Type of Loan
SBA
Only

6 months

Base Rate
Source:

Yes

Spread:

No

If yes, commitment #:

Were you assisted by a City/State entity or a Small Business Development
Center? If yes, please identify below
Name

Street Address

Telephone No.

City

Yes
Fax No.

State

Name and Title of Contact Person

No

Zip + 4

E-mail Address

2. Transaction Information
Products/Goods/Services to be exported (description):
Principle Countries of Export
(please identify the top 3 countries):

Estimated Total Export Sales
to be supported by this Loan:
(Ex-Im Bank applicants only)
U.S. Content Percentage:

EIB-SBA Form 84-1, Revised 05/2015

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OMB No.: 3048-003
Expiration Date: PENDING
Please estimate the number of jobs to be supported
by this Loan:
# of existing jobs maintained

# of additional jobs created

Are Performance Guarantees
or Standby L/Cs to be issued
under this loan?

Yes

No

Percentage of Loan to be
utilized for performance
guarantees:

%

3. Ex-Im Bank applicants only: Please answer the following questions about the “export items” to be
exported from the U.S.
a. Military – Is the buyer or the end user of the export items associated in any
way with the military? Are the items to be used by the military, or are they
defense articles, or do they have a military application? If yes, please attach a
Yes
No
description of the buyer or items as applicable and contact Ex-Im Bank for
approval.
b. Nuclear – Are the export items to be used in the construction, alteration,
operation, or maintenance of the nuclear power, enrichment, reprocessing,
research, heavy water production facilities, nuclear fuel reloads, radioisotopes
Yes
No
for medical and other use, or the handling, treatment, transportation, or
storage of radioactive waste? If yes, please attach a description of the items,
and contact Ex-Im Bank for approval.
c. Environmental – Are the export items to be used for an environmental
project or do they have a perceptible environmental benefit? If yes, please
attach a description of the items and identify the sector in which the items are
Yes
No
to be used, or the sector of the project. If related to a specific project, identify
the project and project location.
d. Munitions – Are the export items on the U.S. Munitions Control List (Part
121 of Title 22 of the Code of Federal Regulations), or do they require a
validated export license from the Bureau of Export Administration? If yes,
Yes
No
please attach a description of the items and contact Ex-Im Bank for approval.
If uncertain whether a validated export license is required, written verification
from the appropriate licensing agency may be required before loan approval.

EIB-SBA Form 84-1, Revised 05/2015

7.

OMB No.: 3048-003
Expiration Date: PENDING

PART C. CERTIFICATIONS
Please attach a signed, duplicate original of Part C for each Borrower and each Lender

1.

Borrower and Lender Certifications

The undersigned, each as authorized representative of the Borrower and the Lender (respectively) and on its behalf, each independently make the following
certifications:
Debarment/Suspension – I certify and acknowledge that neither I nor my Principals have within the past 3 years been a) debarred, suspended, declared ineligible
from participating in, or voluntarily excluded from participation in, a Transaction; b) formally proposed for debarment, with a final determination still pending; c)
indicted, convicted or had a civil judgment rendered against us for any of the offenses listed in the Regulations; d) delinquent on any amounts due and owing to the
U.S. Government or its agencies or instrumentalities as of the date of execution of this certification; or the undersigned has received a written statement of
exception from Ex-Im Bank or SBA attached to this certification, permitting participation in this Transaction despite an inability to make certifications a) through
d) in this paragraph. I further certify that I have not and will not knowingly enter into any agreements in connection with the goods and/or services purchased
with the proceeds of this loan with any individual or entity that has been debarred, suspended, declared ineligible from participating in, or voluntarily excluded
from participation in a Transaction. All capitalized terms not defined herein shall have the meanings set forth in the Government-wide Non-procurement
Suspension and Debarment Regulations (“Regulations”), 2 C.F.R. Part 180 (adopted by reference in 2 C.F.R. part 2700 (SBA Debarment Regulations) and 2 C.F.R.
Part 3513 (Ex-Im Bank Debarment Regulations)).
Compliance with Laws – In addition, I certify that neither I nor anyone acting on my behalf, such as agents, have engaged or will engage in any activity in
connection with this transaction that is a violation of the Foreign Corrupt Practices Act of 1977, 15 U.S.C. 78dd-1, et seq. (which provides for civil and criminal
penalties against individuals who directly or indirectly make or facilitate corrupt payments to foreign officials to obtain or keep business) Further, I have not
engaged, and will not engage, in any activity in connection with this transaction that is a violation of the Arms Export Control Act, 22 U.S.C. 2751 et seq., the
International Emergency Economic Powers Act, 50 U.S.C. 1701 et seq., or the Export Administration Act of 1979, 50 U.S.C. 2401 et seq. I have not been found
by a court of the United States to be in violation of any of these statutes within the preceding 12 months and, to the best of my knowledge, the performance by the
parties to this transaction of their respective obligations does not violate any other applicable law.
Further, neither I nor anyone acting on my behalf in connection with this transaction is currently under charge or has been, within the past 5 years, convicted in any
court or subject to national administrative measures of any country for bribery of foreign public officials.
Lobbying (applicable to Lender only) – If any funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee
of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this commitment
providing for the United States to insure or guarantee a loan, the undersigned shall complete and submit Standard Form-LLL, “Disclosure of Lobbying Activities,”
http://www.exim.gov/pub/ins/pdf/lll.pdf) in accordance with its instructions.
Submission of this statement is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file
the required statement shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.
False Statements – I certify that the representations made and the facts stated in this application and its attachments are true to the best of my knowledge and
belief, and I have not misrepresented or omitted any material facts. I understand that knowingly making false statements or overvaluing a security to obtain a
Government-guaranteed loan can subject me to a fine of up to $250,000 and imprisonment for up to five years under 18 U.S.C. 1001.

Borrower:
Name of Borrower

Signature

Name and Title of Authorized Representative (Print or Type)

Date

Lender:
Name of Lender

Signature

Name and Title of Authorized Representative (Print or Type)

Date

EIB-SBA Form 84-1, Revised 05/2015

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OMB No.: 3048-003
Expiration Date: PENDING

2. Guarantor and Additional Borrower Representations and Certifications
The undersigned, each as authorized representative of the Borrower and the Guarantor(s) (respectively) and on its behalf, each
independently make the following certifications:
ALL QUESTIONS MUST BE ANSWERED AND ARE SUBJECT TO VERIFICATION.
(If any answer to any of these questions below, except for h, is “yes,” provide
complete information on a separate sheet of paper.)
a. Are there any pending or threatened liens, tax liens judgments or material
litigation against the:
b. Does the Borrower or Guarantor or any spouse or member of the household
of the Borrower or Guarantor, or anyone who owns, manages or directs the
Borrower’s business or their spouse or members of their households, work for
SBA (including any former SBA employee separated from SBA for less than 1
year), any Small Business Advisory Council, SCORE, any Federal Agency
(including members of Congress or an appointed official or employee of the
legislative or judicial branch of the Federal Government) or the Lender? (SBA
Applicants only)
c. Has the Borrower or its Associates(s), or the Guarantor(s) ever filed for
protection under U.S. bankruptcy laws? Has either had an involuntary
bankruptcy petition filed against it?
d. Has the Borrower or its Associates(s) or its affiliates, or the Guarantor(s) ever
previously requested U.S. Government financing? (This includes student loans
and disaster loans.)
If yes to d., is any of the financing currently delinquent?
If yes to d., did any of this financing ever default and cause a loss to the
Government?
e.1. Is the Borrower or any of its Associates or the Guarantor(s) presently
subject to an indictment, criminal information, arraignment, or other means by
which formal charges are brought in any jurisdiction?
e.2. Has the Borrower or any of its Associates or the Guarantor(s) been arrested
in the past six months for any criminal offense?
e.3. For any criminal offense (other than a minor vehicle violation) has the
Borrower or any of its Associates or the Guarantor(s) : 1) been convicted; 2)
plead guilty; 3) plead nolo contendere; 4) been placed on pretrial diversion; 5) or
been placed on any form of parole or probation (including probation before
judgment)?
f. Is the Borrower, any of its Associates, or the Guarantor(s) presently debarred,
suspended, proposed for debarment, declared ineligible, or voluntarily excluded
from participation in this transaction by any Federal department or agency?
g. Is any 50% or more owner of the Borrower 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?
h. Are the Borrower and all of its Associates and Guarantors U.S. Citizens?
If no: Are the non-U.S. citizens lawful permanent resident aliens?
Yes Provide alien registration #(s)

Borrower/Associate(s)
of Borrower

Guarantor(s)

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

No

Authorization – I authorize SBA, Ex-Im Bank, and/or the Lender to make inquiries as necessary to verify the accuracy of the
statements made and to determine my creditworthiness.
I authorize the SBA’s 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 applicants only)
Agreements - I agree that if SBA approves this application I will not, for at least two years after the date of SBA’s approval, hire as an
employee or consultant anyone that was employed by the SBA during the one-year period prior to the disbursement of the loan. I
further agree that as consideration for any management, technical and business development assistance that may be provided to me
by SBA or on its behalf, I waive all claims against SBA and its consultants. I understand and agree that I need not pay anybody to
deal with SBA, and that I have read and understand SBA Form 159 (7a), which explains SBA policy on Borrower and Lender

EIB-SBA Form 84-1, Revised 05/2015

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representatives and their fees. By my signature, I certify that I have read the “STATEMENTS REQUIRED BY LAW AND
EXECUTIVE ORDER” included in this application and I agree to comply with all such laws and executive orders.
False Statements - I certify that the representations made and the facts stated in this application and its attachments are true, to the
best of my knowledge and belief, and I have not misrepresented or omitted any material facts. I understand that knowingly making
false statements or overvaluing a security to obtain a Government-guaranteed loan can subject me to a fine of up to $250,000 and
imprisonment for up to five years under 18 U.S.C. 1001, and to the civil remedies available under the False Claims Act, 31 U.S.C.
3729 et seq. I further understand that knowingly making false statements or overvaluing a security to a Federally insured institution
can subject me to a fine of up to $1,000,000 and imprisonment for up to 30 years under 18 U.S.C. 1014.

Borrower:
Name of Borrower

Signature

Name and Title of Authorized Representative (Print or Type)

Date

Guarantor:
Name of Guarantor

Signature

EIB-SBA Form 84-1, Revised 05/2015

Name and Title of Authorized Representative (Print or Type)

Date

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3. Additional Lender Certifications

(SBA applicants only)

The undersigned, as authorized representative of the Lender and on its behalf, make the following certifications:
I approve this application to SBA subject to the terms and conditions stated in this and the attached
documents. Without the participation of SBA, to the extent applied for, we would not be willing to make this
loan, and, in our opinion, the financial assistance approved is not otherwise available on reasonable terms.
I certify that none of the Lender’s Associates, including but not limited to its employees, officers, directors, or
substantial stockholders (more than 10%) have a financial interest in the applicant. I approve and certify that the
applicant is a small business according to standards in 13 CFR Part 121, the loan proceeds will be used for an
eligible purpose, and the owners and managers of the applicant business are of good character.
I certify that the representations made and the facts stated in this application and its attachments are true, to the
best of my knowledge and belief, and I have not misrepresented or omitted any material facts. I understand
that knowingly making false statements or overvaluing a security to obtain a Government-guaranteed loan can
subject me to a fine of up to $250,000 and imprisonment for up to five years under 18 U.S.C. 1001, and to the
civil remedies available under the False Claims Act, 31 U.S.C. 3729 et seq.

Lender:
Name of Lender

Signature

EIB-SBA Form 84-1, Revised 05/2015

Name and Title of Authorized Representative (Print or Type)

Date

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NOTICE TO APPLICANT
Authority for Requiring Submission of Information in Application – The applicant is hereby notified that Ex-Im Bank and SBA
request the information in this application under the authority of the Export-Import Bank Act of 1945, as amended (12 U.S.C. 635 et
seq.) and section 7(a)(14) of the Small Business Act (“SB Act”), (15 U.S.C. 636(a)(14)), respectively. Providing the requested
information is mandatory (except, see Privacy Act notice below concerning social security number), and failure to provide the
requested information may result in SBA/Ex-Im Bank being unable to determine the applicant’s eligibility for financial assistance.
Unless a currently valid OMB control number is displayed on this form (see upper right of each page), SBA/Ex-Im Bank may not
require the information requested in this application, and applicants are not required to provide such information.
Submission of Social Security Number (Privacy Act notice) – Under the Privacy Act, the applicant is not required to provide social
security number information, and failure to provide social security information may not affect any right, benefit, or privilege to which
applicant is entitled. Disclosures of name and other personal identifiers are required for a benefit, however, and SBA requires an
applicant seeking financial assistance to provide sufficient information to allow SBA to make a character and credit determination
concerning individuals that are borrowers, principals, and guarantors. In determining whether an individual is of good character, SBA
considers the person’s integrity, candor, and disposition toward criminal actions. In making loans pursuant to section 7(a) of the SB
Act (15 U.S.C. 636(a)(6)), SBA is required to have reasonable assurance that the loan is of sound value and will be repaid, or that it is
in the best interest of the Government to grant the financial assistance requested. Additionally, SBA is specifically authorized to
verify the applicant’s criminal history, or lack thereof, pursuant to section 7(a)(1) of the SB Act (15 U.S.C. 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 SB Act or the Small Business Investment Act (15 U.S.C. 634 and 687b(a)). For these purposes, applicant is
asked to voluntarily provide social security numbers to assist SBA in making character determinations and to distinguish the
individuals listed in this application 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 provided by that Act. One such routine use is that
when this information indicates a violation or potential violation of law, whether civil, criminal, or administrative in nature, SBA may
refer it 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 to assist in obtaining credit bureau
reports, including business credit reports on the small business borrower and consumer credit reports and scores on the principals of
the small business and guarantors on the loan for purposes of originating, servicing, and liquidating small business loans and for
purposes of routine periodic loan portfolio management and lender monitoring. See 69 F.R. 58598, 58617 (and any subsequently
published notices) for additional background and other routine uses.
Disclosure – Ex-Im Bank and SBA will hold confidential all information provided in the application, subject only to disclosure as
required under the Freedom of Information Act (5 U.S.C. 552), the Privacy Act of 1974 (5 U.S.C. 552a), the Right to Financial Privacy
Act of 1978 (12 U.S.C. 3401), or any other law or court order.
Public Burden Statement – Reporting for this collection of information is estimated to average 2.5 hours per response, including
reviewing instructions, searching data sources, gathering information, and completing and reviewing the application. Send comments
regarding the burden estimate, including suggestions for reducing it, to Office of Management and Budget, Paperwork Reduction
Project OMB# 3048-003, Washington, DC 20503.

STATEMENTS REQUIRED BY LAW AND EXECUTIVE ORDER
Federal executive agencies, including the Small Business Administration (SBA) and the Export-Import Bank (Ex-Im), are 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 provisions of various inter-agency agreements. SBA has issued regulations and
procedures that implement these laws and executive orders, and they are contained in Parts 112, 113, 116, and 117, Title 13, Code of
Federal Regulations Chapter 1, or Standard Operating Procedures.
Freedom of Information Act (5 U.S.C. 552)
This law provides, with some exceptions, that SBA and Ex-IM Bank must supply information reflected in agency files and records to
a person requesting it. SBA information about approved loans that will be automatically released includes, among other things,
statistics on SBA’s 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 information on a borrower contained in either SBA or Ex-Im files
would not routinely be made available to third parties. All requests under this act are to be addressed to the nearest SBA or Ex-Im
Bank office and should be identified as a Freedom of Information request.
Right to Financial Privacy Act of 1978 (12 U.S.C. 3401)
This is notice to you as required by the 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 guarantee. The law provides that SBA shall have a right of access to your financial records in connection with its

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consideration of administration of assistance to you in the form of a Government loan or loan guaranty agreement. 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 or 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 an application for a loan,
or concerning an approved loan or loan guarantee, as necessary to process, service or foreclose on a loan or loan guarantee or to
collect on a defaulted loan or loan guarantee. No other transfer of your financial records to another Government authority will be
permitted by SBA except as required or permitted by law.
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 aggressively collect 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:
•
Report the status of your loan(s) to credit bureaus
•
Hire a collection agency to collect your loan
•
Offset your income tax refund or other amounts due to you from the Federal Government
•
Suspend or debar you or your company from doing business with the Federal Government
•
Refer your loan to the Department of Justice or other attorneys for litigation
•
Foreclose on collateral or take other action permitted in the loan instruments.
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
future financial assistance from SBA under any program, including disaster assistance.
Executive Orders 11988 and 11990 – Floodplain Management and Wetland Protection (42 F.R. 26951 and 42 F.R. 26961)
The SBA discourages any 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 in future floods.
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. In some instances the business can be forced to cease
operations or be prevented from starting operations in a new facility. Therefore, in some instances SBA may require additional
information from an applicant to determine whether the business will be in compliance with OSHA regulations an allowed to operate
its facility after the loan is approved and disbursed. Signing this form as borrower is a certification that the OSHA requirements that
apply to the borrower’s business have been determined and the borrower to the best of its knowledge is in compliance.
Civil Rights Legislations
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 that 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. The Federal agency that administers compliance with this law
concerning this creditor is the Federal Trade Commission, Equal Credit Opportunity, Washington, DC 20580.
Executive Order 11738 – Environmental Protection (38 C.F.R. 25161)
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 environmental protection legislation. SBA must, therefore, impose
conditions on some loans. By acknowledging receipt of this form and presenting the application, the principals of all small businesses
borrowing $100,000 or more in direct funds stipulate to the following:
1. That any facility used, or to be used, by the subject firm is not cited on the EPA list of Violating Facilities.
2. That subject firm will comply with all the requirements of Section 114 of the Clean Air Act (42 U.S.C. 7414) and Section 308 of
the Water Act (33 U.S.C. 1318) relating to the inspection, monitoring, entry, reports and information, as well as all other
requirements specified in Section 114 and Section 308 of the respective Acts, and all regulations and guidelines issued there under.
3. That subject firm will notify SBA of the receipt of any communication from the Director of the Environmental Protection

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Agency indicating that a facility utilized, or to be utilized, by subject firm is under consideration to be listed on the EPA List of
Violating Facilities.
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
(Pub. L. 99-603). 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 or 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 certification that the Immigration Reform and Control Act of 1986 does not apply to
you, of if it does apply, more than five years have elapsed since you have been granted lawful temporary resident status pursuant to
such 1986 legislations.
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,
railings, windows 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 institutional structures where persons reside.

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MAILING/FORWARDING INSTRUCTIONS
Please check the appropriate box(es).
1. If application is submitted by a Borrower/Exporter/Lender:
a. Is Borrower/Exporter’s requested loan amount in Part B $5,000,000 or less?

Yes

No

b. Is Borrower/Exporter a small business, as defined by 13 CFR Part 121?

Yes

No

a. Is Lender an SBA 7(a) Participating Lender?

Yes

No

b. If YES, is Lender using its PLP-EWCP Delegated Authority?

Yes

No

If answer to both of the above is YES, go to Question 2. Below.
If answer to one or both of the above is NO, send entire set of materials to:
Export-Import Bank of the U.S.
Office of Credit Applications and Processing
811 Vermont Ave NW
Washington, DC 20571
2. If application is submitted by a Lender:

If YES to b., a request for a loan number must be sent through SBA’s E-Tran. For E-Tran information go to :
http://www.sba.gov/content/e-tran.
If NO to b., Lender must submit the application via E-Tran (attachments too large for E-Tran may be sent electronically
using Send this File), and notify via e-mail the SBA Regional Manager assigned to the U.S. Export Assistance Center (USEAC)
nearest to the borrower’s location. The contact information for each SBA Regional Manager may be found at:
http://www.sba.gov/content/us-export-assistance -centers.
c. Is Lender using its Ex-Im Bank Delegated Authority?

Yes

No

If YES, send the application, the Loan Authorization Notice (two originals), the appropriate facility fee, and the
$100 application fee to the Ex-Im Bank address above, regardless of the guarantee amount.
FOR SBA USE ONLY
Loan Officer’s Recommendation:
State Reason(s):

Signature:

Approve

Decline

Title:

Other Recommendation if required:
State Reason(s):
Signature:

Date:

Approve

Decline

Title:

Date:

THIS BLOCK TO BE COMPLETED BY SBA OFFICIAL TAKING FINAL ACTION
SBA Final Action:
State Reason(s):
Signature:

EIB-SBA Form 84-1, Revised 05/2015

Approve

Title:

Decline

Date:

15.