Form SBA Form 3514 SBA Form 3514 COVID-19 TARGETED EIDL ADVANCE APPLICATION

OMB Control Number 3245-0419

Expiration Date: 7/31/21

U.S. SMALL BUSINESS ADMINISTRATION

COVID-19 TARGETED EIDL ADVANCE APPLICATION

SBA is collecting the requested information in order to determine whether you are eligible for a Targeted Economic Injury Disaster Loan (EIDL) Advance (Targeted EIDL Advance) and Supplemental Targeted Advance. SBA may provide you with a Targeted EIDL Advance of up to $10,000 for working capital if you meet certain conditions. The combined amount of the Targeted EIDL Advance and any previously received EIDL Advance may not exceed $10,000. In addition, SBA may provide you with a Supplemental Targeted Advance of $5,000. You will not be required to repay the Targeted EIDL Advance, Supplemental Targeted Advance, or EIDL Advance.

If you have questions about this application or problems providing the required information, please contact our Customer Service Center at 1-800-659-2955 or (TTY: 1-800-877-8339) or DisasterCustomerService@sba.gov.

SBA will use information that you previously submitted with your COVID-19 EIDL and EIDL Advance application in addition to new information requested in this application to determine your eligibility. Your response to this application is required for SBA to make that determination.

PRIVACY ACT : The information provided in this form is protected by the Privacy Act, 5 U.S.C 552a, which prohibits the federal government from disclosing personal information about an individual without the individual’s consent. The Privacy Act authorizes SBA to make certain routine uses of information protected by the Act as set forth in its System of Records Notices, 69 F.R. 58598. This form or the information provided in this form may be made available to federal, state, and/or local law enforcement agencies charged with responsibility for or otherwise involved in investigation, prosecution, enforcement or prevention of such violations of law.

PAPERWORK REDUCTION ACT: The estimated time for completing this portion of the application is 30 minutes. You are not required to respond to this or any collection of information unless it displays a currently valid OMB approval number. If you have any questions or comments concerning any aspects of this information collection, please contact the Director, Records Management Division, Small Business Administration, 409 Third Street, SW, Washington, DC 20416 and/or Desk Officer for SBA, Office of Management and Budget, Office of Information and Regulatory Affairs, New Executive Office Building, Washington, DC 20503.

A. ELIGIBILITY QUESTIONS:

Applicant must review and respond to all of the following questions. Please note that “owner” includes each proprietor, each limited partner or LLC member who owns 20% or more interest, each general partner or managing member, and each stockholder or entity owning 20% or more voting stock. If Applicant does not meet the initial eligibility requirements, Applicant will not be able to proceed to the remainder of the application.

1. Are all owners of the Applicant U.S. citizens, non-citizen nationals¹, or qualified aliens²?

☐ Yes

☐ No

2. Is any principal of the Applicant with a 50 percent or greater ownership interest more than sixty (60) days delinquent on child support obligations?

☐ Yes

☐ No

3. In the past year, has any owner of Applicant been convicted of a felony committed during and in connection with a riot or civil disorder or other declared disaster?

☐ Yes

☐ No

4. Has Applicant or owners of Applicant ever been engaged in the production or distribution of any product or service that has been determined to be obscene by a court of competent jurisdiction?

☐ Yes

☐ No

5. Is Applicant or owners of Applicant currently suspended or debarred from contracting with the Federal government or receiving Federal grants or loans?

☐ Yes

☐ No

6. Is any owner of the Applicant currently incarcerated?

☐ Yes

☐ No

7. Is any owner of the Applicant presently subject to an indictment, criminal information, arraignment, or other means by which formal criminal charges are brought in any jurisdiction for any felony?

☐ Yes

☐ No

8. Within the last 5 years, for any felony involving fraud, bribery, embezzlement, or a false statement in a loan application or an application for federal financial assistance, has any owner of the Applicant 1) been convicted; 2) pleaded guilty; 3) pleaded nolo contendere; or 4) commenced any form of parole or probation (including probation before judgment)?

☐ Yes

☐ No

9. Is Applicant engaged in any illegal activity (as defined by Federal guidelines), including selling recreational or medical marijuana?

☐ Yes

☐ No

10. Does Applicant present live performances of a prurient sexual nature or derive directly or indirectly more than de minimis gross revenue through the sale of products or services, or the presentation of any depictions or displays, of a prurient sexual nature?

☐ Yes

☐ No

11. Does Applicant derive more than one-third of gross annual revenue from legal gambling activities?

☐ Yes

☐ No

12. Is Applicant primarily engaged in political or lobbying activities?

☐ Yes

☐ No

13. Is Applicant owned by a state, local, or municipal government entity (other than a tribal business concern, as described in 15 U.S.C. 657a(b)((2)(C))?

☐ Yes

☐ No

14. Is Applicant owned by a member of Congress?

☐ Yes

☐ No

15. Is Applicant an agricultural enterprise (e.g., farm), other than an aquaculture enterprise, agricultural cooperative, or nursery?

☐ Yes

☐ No

16. Is Applicant a nursery farm that derives 50% or more of annual receipts from the production and sale of ornamental plants and other nursery products that they grow?

☐ Yes

☐ No

17. Is Applicant a pawn shop that derived more than 50% of the previous year’s income from interest?

☐ Yes

☐ No

18. Is Applicant engaged in lending or investment?

☐ Yes

☐ No

19. Is Applicant a loan packager that earns more than one-third of its gross annual revenue from packaging SBA loans?

☐ Yes

☐ No

20. Is Applicant engaged in multi-level sales distribution?

☐ Yes

☐ No

21. Is Applicant engaged in real estate development or investment (other than rental properties)?

☐ Yes

☐ No

22. Is Applicant a life insurance company?

☐ Yes

☐ No

23. How many employees does Applicant have as of the date of this Targeted EIDL Advance application?

B. CONFIMATION OF PREVIOUSLY SUBMITTED INFORMATION:

The information below was submitted with your previous application. Please confirm that it is still accurate for your business or organization. Revise any information that has changed. Ensure that the legal name of your business is entered correctly and that it matches your 2019 tax return; this would be the business owner’s name in some cases, such as a Sole Proprietorship or Independent Contractor, where a separate business tax return is not filed. Bank name should be the official name of the bank; please contact your bank if you are unsure. Ensure that you provided a checking account to facilitate the ACH payment. The bank account you provide must satisfy the following: (1) Account opened using your business legal name matching the values entered in the business information section on your application. If you do not have a business legal name, the name on the account must match the business owner’s name; (2) Account has your business address and phone number; (3) Account opened using your business tax identification number (EIN, or SSN if no EIN registered).

1. Legal Name of Business:

2. Is the Applicant a Franchise?

3. Primary Business Address:

Street:

City:

State:

Zip:

4. Business Phone Number:

5. Business Activity (e.g., restaurant, retail):

6. Date Business Established (MM/DD/YY):

7. ACH Information

Bank Name:

Routing Number:

Account Number:

8. Amount of EIDL Advance previously received:

Is information in questions 1 – 8 above correct?

☐ Yes

☐ No

C. NEW INFORMATION:

1. Please provide contact information for questions on this application:

Phone number:

2. Complete the monthly gross receipts for each year listed on the form. Gross receipts include all revenue in whatever form received or accrued, from whatever source. If there was a period with no sales, please enter 0.

Month	Fiscal year 2019	Fiscal year 2020	Current year/ to date: 2021
January
February
March
April
May
June
July
August
September
October
November
December

3. I would like to be considered for a Supplemental Targeted Advance of $5,000.

☐ Yes

☐ No

WARNING: Any false statement or misrepresentation to SBA may result in criminal, civil or administrative sanctions including, but not limited to: 1) fines and imprisonment, or both, under 15 U.S.C. 645, 18 U.S.C. 1001, 18 U.S.C. 1014, 18 U.S.C. 1040, 18 U.S.C. 3571, and any other applicable laws; 2) treble damages and civil penalties under the False Claims Act, 31 U.S.C. 3729; 3) double damages and civil penalties under the Program Fraud Civil Remedies Act, 31 U.S.C. 3802; and 4) suspension and/or debarment from all Federal procurement and non-procurement transactions. Statutory fines may increase if amended by the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015.

☐ I hereby certify UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES that the above is true and correct.

NOTE: If your application meets threshold eligibility requirements for the Targeted EIDL Advance, you will receive an email requesting that you log in to the customer account portal to complete and sign a Request for Transcript of Tax Return (IRS Form 4506-T) for your business or organization. You must complete this task in order for your application to be considered. Submitting this form does not guarantee that your application will be approved.

For Applicants that are Limited Liability Companies: please select which form was used for the Applicant business’s 2019 tax return:

☐ Form 1040 (Schedule C, E, or F)

☐ Form 1065 (Partnership)

☐ Form 1120S (S Corporation)

☐ Form 1120 (Corporation)

1 Non-Citizen National is defined in 8 U.S.C. 1408: Unless otherwise provided in 8 U.S.C. 1401, the following shall be nationals, but not citizens, of the United States at birth:

a. A person born in an outlying possession of the United States on or after the date of formal acquisition of such possession;

b. person born outside the United States and its outlying possessions of parents both of whom are nationals, but not citizens, of the United States, and have had a residence in the United States, or one of its outlying possessions prior to the birth of such person;

c. A person of unknown parentage found in an outlying possession of the United States while under the age of five years, until shown, prior to his attaining the age of twenty-one years, not to have been born in such outlying possession; and

d. A person born outside the United States and its outlying possessions of parents one of whom is an alien, and the other a national, but not a citizen, of the United States who, prior to the birth of such person, was physically present in the United States or its outlying possessions for a period or periods totaling not less than seven years in any continuous period of ten years.

(1) During which the national parent was not outside the United States or its outlying possessions for a continuous period of more than one year, and

(2) At least five years of which were after attaining the age of fourteen years.

2 Qualified Alien is defined in 8 U.S.C 1641(b): The term “qualified alien” means an alien who, at the time the alien applies for, receives, or attempts to receive a Federal public benefit, is:

a. An alien who is lawfully admitted for permanent residence under the Immigration and Nationality Act (8 U.S.C. 1101 et seq.),

b. An alien who is granted asylum under 8 U.S.C. 1158,

c. A refugee who is admitted to the United States under 8 U.S.C. 1157.

d. An alien who is paroled into the United States under 8 U.S.C. 1182(d)(5) for a period of at least 1 year,

e. An alien whose deportation is being withheld under 8 U.S.C. 1253 (as in effect immediately before the effective date of § 307 of division C of Public Law 104–208) or § 241(b) (3) of such Act [8 U.S.C. 1231 (b)(3)] (as amended by § 305(a) of division C of Public Law 104–208),

f. An alien who is granted conditional entry pursuant to 8 U.S.C. 1153 (a)(7) as in effect prior to April 1, 1980; or

g. An alien who is a Cuban and Haitian entrant (as defined in § 501(e) of the Refugee Education Assistance Act of 1980).

SBA Form 3514 (04/21)