SBA Form 994 H DEFAULT REPORT, CLAIM FOR REIMBURSEMENT, REPORT OF RECOV

O MB 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 # 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: Click or tap here to enter text.	Business Name: Click or tap here to enter text.
Surety Name: Click or tap here to enter text.	990 Date: (see instructions) Click or tap here to enter text.
Bond Number: Click or tap here to enter text.	Contract Amount $: Click or tap here to enter text.
Claim Number: Click or tap here to enter text.	Obligee: Click or tap here to enter text.
Project: Click or tap here to enter text.
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) Click or tap here to enter text.	Default Date: Click or tap here to enter text.
Last Status Report Date: Click or tap here to enter text.
Close Date: (SBA USE ONLY)Click or tap here to enter text.	☐ No Change from previous Report ☐ Status Update Included: (Describe below, current status and default completion plans)
SBA’s Reserve Amount $: Click or tap here to enter text.	Surety Reserve Amount $: Click or tap here to enter text.

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.)

Click or tap here to enter text.

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 $: Click or tap here to enter text.	Amount Approved $: Click or tap here to enter text.			Effective Date (SBA Received): Click or tap here to enter text.
Recommended By: Title: Click or tap here to enter text. Signature: Click or tap here to enter text. Date: Click or tap here to enter text.		Reviewer: Initial: Click or tap here to enter text. Date: Click or tap here to enter text.	2nd Reviewer: Initial: Click or tap here to enter text. Date: Click or tap here to enter text.		Approving Official: Title: Click or tap here to enter text. Signature: Click or tap here to enter text. Date: Click or tap here to enter text.

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	RECOVERY CLASS
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 ☐		or TOTAL DUE AND SUBMITTED TO SBA ☐

H. CERTIFICATION
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: Click or tap here to enter text.	Area Code/Phone No.: Click or tap here to enter text.	Surety Certifying Official’s: Title: Click or tap here to enter text. Signature: Click or tap here to enter text. Date: Click or tap here to enter text.

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-or-agent. 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:

   1. 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.

Section A.	“990 Date” is the date SBA Form 990, “Surety Bond Guarantee Agreement,” was signed by SBA Official. DEFAULT REASON CODES:
	CODE Underbidding Weather/natural disasters Shortage in critical materials/ Delays in receiving same Alleged embezzlement Financial mismanagement Incompetence/poor workmanship Union strike/labor trouble Illness or death of key employee Walked off job Dispute with obligee Possible fraudulent operation on part of principal Despondency Co-mingling of funds	CODE General’s subcontractor in default Sub’s General in default Possible sub-busting on part of general IRS lien Sub’s General behind Schedule Unforeseen physical obstacle Shortage of labor Principal fails to appear at job site to begin work Fire damage Materialman lien Labor lien Principal failed to sign contract Surety did not issue final bond Other
Section E.	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.”
Section F.	List all recovery items received by the Surety. Also, list as recovery, all trust account remaining balances returned by the trustee.
Section G.	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 3^rd 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 Page 9 of 9