Download:
pdf |
pdfApply for a SBA Disaster Loan
for your Business
OMB No. 324500017
Expiration Date: 00/00/00
Use this form to apply for a low-interest, long-term loan from the SBA for
physical and economic damage caused by a declared disaster.
Information to prepare
It will be helpful to collect the following items to fill out this application:
•
The most recent federal tax return for your business
•
Information about all insurance policies for your business
•
Information about all general partners or managing members of your business
•
Information about any persons or entities who own 20% or more of the business
•
You will also need the designated disaster number. You can find this at sba.gov/disaster
Disaster declaration
1
Which disaster event affected you?
To qualify for a disaster loan from SBA, your
business needs to be affected by a federallydeclared disaster. These disasters have a
five-digit Disaster Number following the state
abbreviation.
This number is available at sba.gov/disaster
or at a Disaster Recovery Center.
DISASTER NUMBER
e.g. TX - 01234
Note: If you are applying for a Military Reservist Economic Injury Loan
(MREIDL), you should use your unique Disaster Number starting with ZZ-
Business name
2
What is the legal name of your
business impacted by this disaster?
The business name on your federal tax return
2a If your business uses
another name, please
enter it here (optional)
Such as a trade name, or DBA
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Locations affected by the disaster
3
What address for your business was
affected by the disaster event?
Provide the address of your business location
that experienced physical damage or
economic injury from the disaster.
If you include an address that is not within the
bounds of the declared disaster area, your
application may be denied.
ADDRESS LINE 1
ADDRESS LINE 2 (Optional)
STATE
CITY
ZIP CODE
I own this space
I lease this space
3a Additional business
ADDRESS LINE 1
address (optional)
If you have an additional
business location that
experienced physical damage
or economic injury, provide its
address here.
If you need more space for
additional locations, please
include them on a separate
piece of paper using the same
format, with your name and
business name included at the
top. Please ensure it is bundled
with this application.
ADDRESS LINE 2 (Optional)
STATE
CITY
ZIP CODE
I own this space
I lease this space
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What’s damaged
4
What items were damaged
or destroyed?
Select all that apply.
If your business has been impacted by the
disaster such that you have had lost your
ability to meet your financial obligations and
operating expenses, choose “Loss of capital”.
Select all that apply:
The structure of my business
Business furniture, equipment and/or inventory
Business transportation vehicles (car, truck, boat, other)
Loss of working capital (also called Economic Injury)
Military Reservist Economic Injury
4a If you selected
Military Reservist
Economic Injury, include
the name and Social
Security Number of the
Reservist
If the Reservist is also the sole
owner of the business, check
the box below.
NAME OF RESERVIST EMPLOYEE
EMPLOYEE’S SOCIAL SECURITY NUMBER
-
-
This person is also the sole owner of the business
If you need more space for
additional reservists, please
include them on a separate
piece of paper using the same
format, with your name and
business name included at the
top. Please ensure it is bundled
with this application.
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About your business
5
What is your Federal Tax ID?
If you used an Employer Identification Number
(EIN) to file your most recent federal taxes,
provide your Employee Identification Number
If you are a Sole Proprietorship or Independent
Contractor and filed taxes for your business
using your Social Security Number, provide
your Social Security Number
6
Which 6-digit NAICS code best
describes your business?
This is a 6-digit code that you may have
included on your taxes as a “Business Activity
Code” or “Business Code Number”.
A list of these codes is available in the IRS
Instructions for Schedule C, under “Principal
Business or Professional Activity Codes” at
the bottom of irs.gov/instructions/i1040sc
7
How is your business structured?
Sole Proprietorship
Joint Venture
Select the structure that you selected in your
most recent federal tax return
Cooperative
Limited Liability
Company (LLC)
Corporation: C-Corp
Corporation: S-Corp
Employee Stock
Ownership (ESOP)
Housing Cooperative
Independent Contractor
8
Non-profit
Partnership,
General or Limited
Professional Association
Qualified Joint Venture
Trust
How many employees did you have at
the time of the disaster event?
Write the number of employees at the time
the disaster occurred, including yourself.
We understand that this number may be
different from the current number.
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Insurance coverage
9
If you have Hazard Insurance,
provide the following information
NAME OF HAZARD INSURANCE COMPANY
If not, leave blank.
If you have received money from your
insurance already, please make note of the
amount in the last box.
INSURANCE POLICY NUMBER
CURRENT AMOUNT RECEIVED FROM INSURANCE COMPANY, IF ANY
10 If you have Business Interruption
Insurance, provide the following
information
NAME OF BUSINESS INTERRUPTION INSURANCE COMPANY
If not, leave blank.
If you have received money from your
insurance already, please make note of the
amount in the last box.
INSURANCE POLICY NUMBER
CURRENT AMOUNT RECEIVED FROM INSURANCE COMPANY, IF ANY
11 If you have Flood Insurance, provide
NAME OF FLOOD INSURANCE COMPANY
the following information
If not, leave blank.
If you have received money from your
insurance already, please make note of the
amount in the last box.
INSURANCE POLICY NUMBER
CURRENT AMOUNT RECEIVED FROM INSURANCE COMPANY, IF ANY
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Insurance coverage, continued
12 If you have Windstorm Insurance,
NAME OF WINDSTORM INSURANCE COMPANY
provide the following information
If not, leave blank.
If you have received money from your
insurance already, please make note of the
amount in the last box.
INSURANCE POLICY NUMBER
CURRENT AMOUNT RECEIVED FROM INSURANCE COMPANY, IF ANY
13 If you have separate Fire Insurance,
NAME OF FIRE INSURANCE COMPANY
provide the following information
If not, leave blank.
If you have received money from your
insurance already, please make note of the
amount in the last box.
INSURANCE POLICY NUMBER
CURRENT AMOUNT RECEIVED FROM INSURANCE COMPANY, IF ANY
About the owners
14 What date did you establish
MONTH
DAY
YEAR
or acquire your business?
14a
If this date was within the past
year, provide additional details
If you acquired an existing business,
provide details about dates, and
include the percentage of ownership
of all owners of the business.
If this is a new business, state that
this is a new business.
If you need more space, attach
additional pages.
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Complete the following sections for each person who is a general
partner, managing member, or owner of 20% or more of your business.
About you - Owner 1
15 What is your legal name?
FULL NAME (FIRST, MIDDLE, LAST)
Provide your full legal name.
If you are a business entity, provide your
legal entity name as filed on your taxes
or
ENTITY NAME
ENTITY EIN NUMBER
16 What is your date of birth?
MONTH
DAY
YEAR
Provide the month, day, and year
17 What is your Social Security Number?
Provide your 9-digit SSN or ITIN
-
-
18 What is your email address?
This is the primary method that we will use to
contact you about your application, and will
be used for logging in to our online portal.
This email may also be used to send you
closing documents for signing on your loan
19 What is your primary phone number?
We will use this number to contact you for
questions and updates about your application
-
-
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About you, continued - Owner 1
19a
-
Do you have an additional phone
number we should use?
-
We will use this number if we cannot
reach your primary phone number
20 What percentage of
the business do you own?
21 Do you own more than 50%
of any other businesses?
22 Are you a partner or managing
member for any other businesses?
%
Yes, I own more than 50% of another business
No, I do not own more than 50% of any other business
Yes, I am a partner or managing member
for another business
No, I am not a partner or managing member
for another business
23 Are you married?
Provide your current marital status so we can
confirm your information with the IRS.
24 Are you a United States citizen?
If your answer is “No,” we may contact you
to learn more about your citizenship status.
You may need to provide a copy of specific
documents like a green card or proof of
permanent residency.
24a
Yes, I am married
No, I am not married
Yes, I am a United States citizen
No, I am not a United States citizen
If no, please provide a
registration number.
This is the “alien registration
number” provided by US
Citizenship and Immigration.
I do not have a registration number
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Demographic information - Owner 1
25a
Are you a veteran,
or the spouse of a veteran?
Optional
I am a veteran
I am a service-disabled veteran
I am the spouse of a veteran
I am not a veteran
Prefer not to answer
25b
With which gender do you identify?
Male
Optional
Female
Other
Prefer not to answer
25c
What is your ethnicity?
Hispanic or Latino
Optional
Not Hispanic or Latino
Prefer not to answer
25d
What is your race?
American Indian or Alaska Native
Optional, Select all that apply
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Prefer not to answer
Note
Veteran, gender, race, and ethnicity data is collected for program reporting only.
Disclosure is voluntary and has no bearing on the loan decision.
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About you - Additional owner, general partner, or managing member
Copy this section for each person who is a general partner,
managing member, or owner of 20% or more of your business
A1
What is your legal name?
FULL NAME (FIRST, MIDDLE, LAST)
Provide your full legal name.
If you are a business entity, provide your
legal entity name as filed on your taxes
or
ENTITY NAME
A2
What is your date of birth?
MONTH
DAY
YEAR
Provide the month, day, and year
A3
What is your Social Security Number?
Provide your 9-digit SSN or ITIN
A4
A5
-
-
Are you married?
Yes, I am married
Provide your current marital status
No, I am not married
Are you a United States citizen?
Yes, I am a United States citizen
If your answer is “No,” we may contact you
to learn more about your citizenship status.
You may need to provide a copy of specific
documents like a green card or proof of
permanent residency.
No, I am not a United States citizen
A5a
If no, please provide a
registration number.
This is the “alien registration
number” provided by US
Citizenship and Immigration.
I do not have a registration number
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About you - Additional owner, general partner, or managing member
Provide the first and last name for this person
(this will help us keep track across pages)
A6
What percentage of
the business do you own?
A7
Do you own more than 50%
of any other businesses?
Yes, I own more than 50% of another business
Are you a partner or managing
member for any other businesses?
Yes, I am a partner or managing member
for another business
A8
%
No, I do not own more than 50% of any other business
No, I am not a partner or managing member
for another business
A9
What is your email address?
This is the primary method that we will use to
contact you about your application, and will
be used for logging in to our online portal.
This email may also be used to send you
closing documents for signing on your loan
A10
What is your primary phone number?
We will use this number to contact you for
questions and updates about your application
A10a
Do you have an additional phone
number we should use?
-
-
-
-
We will use this number if we cannot
reach your primary phone number
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Demographic information - Additional owner, partner, or managing member
Provide the first and last name for this person
(this will help us keep track across pages)
A11
Are you a veteran,
or the spouse of a veteran?
Optional
I am a veteran
I am a service-disabled veteran
I am the spouse of a veteran
I am not a veteran
Prefer not to answer
A12
With which gender do you identify?
Male
Optional
Female
Other
Prefer not to answer
A13
What is your ethnicity?
Hispanic or Latino
Optional
Not Hispanic or Latino
Prefer not to answer
A14
What is your race?
American Indian or Alaska Native
Optional, Select all that apply
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Prefer not to answer
Note
Veteran, gender, race, and ethnicity data is collected for program reporting only.
Disclosure is voluntary and has no bearing on the loan decision.
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Criminal background and delinquencies
26 Is the following true for the business, or any general partner,
managing member, or owner with 20% or more ownership?
26a
26b
26c
26d
26e
26f
26g
Filed bankruptcy in the past 2 years
Yes
No
Have outstanding judgments, tax liens,
or pending lawsuits against them
Yes
No
Presently incarcerated, or on probation or parole
following conviction for a serious criminal offense
Yes
No
In the past year, been convicted of a felony
committed during and in connection with
a riot or civil disorder or other declared disaster
Yes
No
Ever been engaged in the production or
distribution of a product or service that has been
determined obscene by a court of competent
jurisdiction
Yes
No
Currently more than 60 days late on
paying any child support obligations
Yes
No
Currently suspended or debarred from
contracting with the Federal government
or receiving Federal grants or loans
Yes
No
If you answered “Yes” to any of the questions above, use this space to provide dates
and details about each occurrence. If you need more space, attach additional sheets.
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Primary Point of Contact
27 Who should be the primary point of
NAME OF POINT OF CONTACT
contact for your loan application?
This is the primary person that we will contact
with questions about your application.
It should be someone who has authority to
make decisions and sign legal documentation
on behalf of your business.
TITLE / ROLE AT YOUR BUSINESS
28 What is their email address?
This is the primary method that we will use to
contact them about your application
My business does not have an email address
-
29 What is their phone number?
We will use this number to contact them for
questions and updates about your application
-
I want to receive updates about my loan via text message
(optional, messaging rates may apply)
29a
-
Is there an additional phone
number we should use? (optional)
-
We will use this number if we cannot
reach the phone number above
30 Would you like us to use an alternative
ADDRESS LINE 1
address for sending mail about your
application? (optional)
We understand that you may need to move
as part of the process of recovery, and we will
be sending all of our notifications through our
online portal, email, or phone to reach you as
quickly as possible.
If you would like to receive letters about your
loan at a different address than your business
address, you can provide that here
ADDRESS LINE 2 (Optional)
STATE
CITY
ZIP CODE
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Paid Agent Information
31 Did you pay to anyone support you in
completing this application?
This could be an accountant, packager, or
attorney that worked for a fee.
If yes, provide their name, company, and any
fee charged or agreed upon for their services.
If no, leave blank.
AGENT FULL NAME
AGENT COMPANY (If applicable)
ADDRESS LINE 1
ADDRESS LINE 2 (Optional)
STATE
CITY
ZIP CODE
FEE FOR SERVICES
$
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E-SIGN Disclosure and Consent
32 Do you consent to using electronic signatures and electronic communications?
While you are currently filling out a paper form, there may come a time or opportunity where you would
like to receive or sign documents electronically. By checking this consent box, you give us permission
to communicate with you electronically (including billing notifications). In addition, this consent gives us
permission to use your electronic signature for any future documents.
Please read the following information carefully. By checking “I Agree”, you are agreeing that you have reviewed this information and consent to
conduct business with the U.S. Small Business Administration using Electronic Communications and using an electronic signature instead of a
written signature. Communications provided to you in electronic format will be considered to be “in writing” in accordance with the Electronic
Signatures in Global and National Commerce Act.
In this document: “SBA” means the U.S. Small Business Administration; “You” and “your” means the signatory authorized to enter this agreement;
“Communication” or “Electronic Communication” means each disclosure, contract, agreement, statement, record, document, invoice, or other
information that SBA provides to you or that you submit to SBA that may be required by law; and, “Loan” or “transaction” means the SBA Disaster
Loan to which you are applying.
Consent to Use Electronic Signatures: You consent to using electronic signatures for all documents, contracts, agreements, or disclosures
related to this loan. You agree that your use of any device, means, or action to provide your electronic signature constitutes your acceptance and
agreement to the terms and conditions of each document as if actually signed by you in writing. You also agree that no certification authority
or other third party verification is necessary to validate your electronic signature, and that the lack of such certification or third party verification
will not in any way affect the enforceability of your electronic signature. You are confirming that you are the party authorized to enter into this
agreement. You further agree that each use of your electronic signature constitutes your agreement to be bound by the terms and conditions of
each document.
Consent to Electronic Communications: You consent to use and receipt of Communications in electronic format. This consent covers all
Communications related to this transaction. Your consent remains in effect unless and until it is withdrawn. Note that SBA may nevertheless
provide you with some Communications in written, signed, or nonelectronic form.
Withdrawing Consent: You may withdraw your consent to Electronic Communications at any time by opting out in the Loan Application Portal
or by sending your request in writing to DisasterCustomerService@sba.gov.
This withdrawal will become effective within a reasonable period of time to process your withdrawal. Withdrawal does not apply to any
Electronic Communications provided or made available to you prior to the effectiveness of the withdrawal.
There are no conditions, consequences, or fees associated with withdrawing your consent.
Your Right to Receive Paper Copies: You may print a paper copy of any Electronic Communication, or request a copy by contacting the SBA
Disaster Customer Service Center at DisasterCustomerService@sba.gov or 1-800-659-2955. There is no fee for requesting a paper copy of an
Electronic Communication.
Hardware and Software Requirements: To access, view, and retain Electronic Communications, you must have:
•
A connection to the Internet;
•
A supported Internet Browser;
•
Software that is capable of receiving, accessing, and
displaying Electronic Communications from SBA,
whether presented online, in email, or in PDF form;
•
A printer, hard drive, or other storage device
if you wish to print or download and save Electronic
Communications; and,
•
A device and operating system that supports the above.
Changes to Hardware and Software Requirements: If SBA’s hardware and/or software requirements change, and that change would create a
material risk that you would not be able to access or retain your Electronic Communications, SBA will give you notice of the revised hardware or
software requirements, including a reminder of your right to withdraw consent to Electronic Communications.
You Must Keep Your Contact Information Current: You are responsible for maintaining current contact information, such as email addresses and
cell phone number, with SBA to continue receiving Electronic Communications. You may update your contact information by contacting the SBA
Disaster Customer Service Center at DisasterCustomerService@sba.gov or 1-800-659-2955.
Yes, I consent to electronic signatures and electronic communications
No, I do not consent to electronic signatures and electronic communications
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Consent and signature
33 Do you agree to the following terms?
If you agree and have the authority to, sign below with your signature, title, and today’s date.
On behalf of the undersigned individually and for the applicant business:
I/We authorize my/our insurance company, bank, financial institution, or other creditors to release to SBA all records and information necessary
to process this application.
If my/our loan is approved, additional information may be required prior to loan closing. I/We will be advised in writing what information will be
required to obtain my/our loan funds.
I/We hereby authorize the SBA to verify my/our past and present employment information and salary history as needed to process and service a
disaster loan.
I/We authorize SBA, as required by the Privacy Act, to release any information collected in connection with this application to Federal, state,
local, tribal or nonprofit organizations (e.g. Red Cross Salvation Army, Mennonite Disaster Services, SBA Resource Partners) for the purpose of
assisting me with my/our SBA application, evaluating eligibility for additional assistance, or notifying me of the availability of such assistance.
I/We will not exclude from participating in or deny the benefits of, or otherwise subject to discrimination under any program or activity for which
I/we receive Federal financial assistance from SBA, any person on grounds of age, color, handicap, marital status, national origin, race, religion,
or sex.
I/We will report to the SBA Office of the Inspector General, Washington, DC 20416, any Federal employee who offers, in return for compensation
of any kind, to help get this loan approved. I/We have not paid anyone connected with the Federal government for help in getting this loan.
If my loan is approved, I may be eligible for mitigation – additional funds up to 20 percent of the total SBA verified physical losses - to safeguard
my property from future damages. I am not obligated to accept these additional funds. If I do accept these additional funds for mitigation, I
agree to only use them for mitigation purposes as specified in my loan agreement.
I have received and read a copy of the “STATEMENTS REQUIRED BY LAWS AND EXECUTIVE ORDERS” which was attached to this application.
CERTIFICATION AS TO TRUTHFUL INFORMATION: By signing this application, you certify that all information in your application and submitted
with your application is true and correct to the best of your knowledge, and that you will submit truthful information in the future.
WARNING: Whoever wrongfully misapplies the proceeds of an SBA disaster loan shall be civilly liable to the Administrator in an amount equal to
one-and-one half times the original principal amount of the loan under 15 U.S.C. 636(b).
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.
BUSINESS NAME
MONTH
DAY
SIGNATURE
FULL NAME AND TITLE
YEAR
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Additional information about this form
This form is for use by Businesses to apply for an SBA physical or economic injury disaster loan as applicable.
The requested information is required to obtain a benefit under our SBA Disaster Loan Program and helps the
Agency determine whether the applicant is eligible for a disaster loan and has repayment ability.
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 disastercustomerservice@sba.gov. If more space is needed for any
section of this application, please attach additional sheets. SBA will contact you by phone or email to discuss your
loan request.
You may submit the form:
• Online on SBA’s secure website www.sba.gov
• In-person at a disaster recovery center
• By mail:
U.S. Small Business Administration, Processing and Disbursement
14925 Kingsport Rd. Ft. Worth, TX 76155-2243
SBA will contact you by phone or email to discuss your loan request.
Filing requirements
For all applications, excluding non-profit organizations, the following items must be submitted:
•
This application (SBA Form 5), completed and signed
•
Request for Transcript of Tax Returns (IRS Form 4506C), completed and signed by each applicant, each
principal owning 20 percent or more of the applicant business, each general partner or managing member;
and for any owner who has greater than 50 percent ownership in an affiliate business. Affiliates include,
but are not limited to, business parents, subsidiaries, and/or other businesses with common ownership or
management
•
Complete copies, including all schedules, of the most recent Federal income tax returns for the applicant
business; an explanation if not available
•
Personal Financial Statement (SBA Form 413) completed, signed, and dated by the applicant, each principal
owning 20 percent or more of the applicant business, and each general partner or managing member
•
Schedule of Liabilities listing all fixed debts (SBA Form 2202 may be used)
Additional requirements for Military Reservist Economic Injury (MREIDL):
•
A copy of the essential employee’s notice of expected call-up to active service (as defined in 10 U.S.C. 101(d)
(3)) for a period of more than 30 consecutive days or official call-up orders, or release/discharge from active
service
•
A written explanation and financial estimate of how the call-up of the essential employee has or will result in
economic injury to your business, and the steps your business is taking to alleviate the economic injury
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Filing requirements, continued
For non-profit organizations (houses of worship, associations, etc), the following items must be
submitted:
•
This application (SBA Form 5), completed and signed
•
A complete copy of the organization’s most recent tax return OR a copy of the organization’s IRS tax-exempt
certification and complete copies of the organization’s three most recent years’ “Statement of Activities”
•
Schedule of Liabilities listing all fixed debts (SBA Form 2202 may be used)
Request for Transcript of Tax Returns (IRS Form 4506C), completed and signed by each applicant and for any
affiliated entity. Affiliates include, but are not limited to, business parents, subsidiaries, and/or other businesses
with common ownership or management
Additional information may be necessary to process your application. If requested, please
provide within 7 days of the information request.
•
Complete copy, including all schedules, of the most recent Federal income tax return for each principal
owning 20 percent or more, each general partner or managing member, and each affiliate when any owner
has more than 50 percent ownership in the affiliate business. Affiliates include, but are not limited to, business
parents, subsidiaries, and/or other businesses with common ownership or management
•
If the most recent Federal income tax return has not been filed, a year-end profit-and-loss statement and
balance sheet for that tax year
•
A current year-to-date profit-and-loss statement
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Statements required by Laws and Executive Orders
Note: Please read, detach, and keep for your records
To comply with legislation passed by the Congress and Executive Orders issued by the President, Federal
executive agencies, including the Small Business Administration (SBA), must notify you of certain information. You
can find the regulations and policies implementing these laws and Executive Orders in Title 13, Code of Federal
Regulations (CFR), Chapter 1, or our Standard Operating Procedures (SOPs). In order to provide the required
notices, the following is a brief summary of the various laws and Executive Orders that affect SBA’s Disaster Loan
Programs. A glossary of terms can be found at disasterloanassistance.sba.gov/ela/s/loan-information
The Small Business Act, Public Law (PL) 85-536 authorizes the Small Business Administration (SBA) to collect
the information on this form. Your disclosure of the information is voluntary. However, failure to disclose certain
information may delay the processing of your eligibility or denial. The SBA will not deny eligibility if you refuse to
disclose your Social Security Number. This information is collected to participate in a loan or grant to determine
eligibility for a SBA program. The information collected may be released to appropriate Federal, State and Local
Agencies, credit bureaus and Servicing agents when relevant to civil, criminal, or regulatory proceedings or to
enforce regulations by manual or automated verification procedures.
STATEMENT REGARDING LOBBYING (APPLICABLE ONLY TO LOANS EXCEEDING $150,000)
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 provide a loan, the
Applicant(s) will complete and submit Standard Form LLL, “Disclosure of Lobbying Activities,” in accordance with
13 CFR Part 146. Applicant(s) acknowledges submission of this disclosure is a prerequisite for making or entering
into this transaction imposed by Section 1352, Title 31, U.S. Code, and that any person who fails to file or amend
a declaration required to be filed or amended will be subject to a civil penalty in the amounts set forth in 13 CFR
§146.400.
FREEDOM OF INFORMATION ACT (5 U.S.C. 552)
This law provides, with some exceptions, that we must make records or portions of records contained in our files
available to persons requesting them. This generally includes aggregate statistical information on our disaster
loan programs and other information such as names of borrowers (and their officers, directors, stockholders or
partners), loan amounts at maturity, the collateral pledged, and the general purpose of loans. We do not routinely
make available to third parties your proprietary data without first notifying you, required by Executive Order
12600, or confidential business information, information that would cause competitive harm, or information that
would constitute a clearly unwarranted invasion of personal privacy.
For information about the FOIA, contact the Chief, FOI/PA Office, 409 3rd Street, SW, Suite 5900, Washington, DC
20416, or by e-mail at foia@sba.gov.
PRIVACY ACT (5 U.S.C. 552a)
Anyone can request to see or get copies of any personal information that we have in your file. Any personal
information in your file that is retrieved by individual identifiers, such as name or social security number, is
protected by the Privacy Act, which means requests for information about you may be denied unless we have your
written permission to release the information to the requester or unless the information is subject to disclosure
under the Freedom of Information Act. The Agreements and Certifications section of this form contains written
permission for us to disclose the information resulting from this collection to state, local or private disaster relief
services.
The Privacy Act authorizes SBA to make certain “routine uses” of information protected by that Act. One such
routine use for SBA’s loan system of records 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 of personal information is to assist in obtaining
credit bureau reports, on the Disaster Loan Applicants and guarantors for purposes of originating, servicing, and
liquidating Disaster loans. See, 86 FR 64979 (and as amended from time to time) for additional background and
other routine uses.
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Statements required by Laws and Executive Orders, continued
Under the provisions of the Privacy Act, you are not required to provide social security numbers. (But see the
information under Debt Collection Act below). In addition to the reasons described below, we use social security
numbers to distinguish between people with a similar or the same name for credit decisions and for debt
collection purposes. Failure to provide this number may not affect any right, benefit, or privilege to which you are
entitled by law, but having the number makes it easier for us to more accurately identify to whom adverse credit
information applies and to keep accurate loan records.
Note: Any person concerned with the collection, use and disclosure of information, under the Privacy Act may
contact the Chief, FOI/ PA Office, 409 3rd Street, SW, Suite 5900, Washington, DC 20416 or by e-mail at foia@sba.
gov for information about the Agency’s procedures relating to the Privacy Act and the Freedom of Information Act.
DEBT COLLECTION ACT OF 1982 (5 U.S.C. 5514 note); DEBT COLLECTION IMPROVEMENT ACT OF 1996, as
amended (31 U.S.C. 3701 et seq.)
These laws require us to aggressively collect any delinquent loan payments and/or to require you to give your
taxpayer identification number to us when you apply for a loan (31 U.S.C. 7701). If you receive a loan and do not
make payments when they become due, we may take one or more of the following actions (this list may not be
exhaustive):
•
Report the delinquency to credit reporting bureaus.
•
Offset your income tax refunds or other amounts due to you from the Federal Government.
•
Refer the account to a private collection agency or other agency operating a debt collection center.
•
Suspend or debar you from doing business with the Federal Government.
•
Refer your loan to the Department of Justice.
•
Foreclose on collateral or take other actions permitted in the loan instruments.
•
Garnish wages.
•
Sell the debt.
•
Litigate or foreclose.
RIGHT TO FINANCIAL PRIVACY ACT OF 1978 (12 U.S.C. 3401 et seq.)
This notifies you, as required by the Right to Financial Privacy Act of 1978 (Act), of our right to access financial
records held by financialinstitutions that were or are doing business with you or your business. This includes
financial institutions participating in loans or loan guarantees.
The law provides that we may access your financial records when considering or administering Government loan
or loan guaranty assistance to you. We must give a financial institution a certificate of our compliance with the Act
when we first request access to your financial records.
No other certification is required for later access. Our access rights continue for the term of any approved loan or
loan guaranty. We do not have to give you any additional notice of our access rights during the term of the loan or
loan guaranty.
We may transfer to another Government authority any financial records included in a loan application or about an
approved loan or loan guaranty as necessary to process, service, liquidate, or foreclose a loan or loan guaranty.
We will not permit any transfer of your financial records to another Government authority except as required or
permitted by law.
PAPERWORK REDUCTION ACT (44 U.S.C. Chapter 35)
We are collecting the information on this form in order to make disaster loans available to qualified applicants.
The form is designed to collect the information necessary for us to make eligibility and credit decisions in order to
fund or deny loan requests.
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Statements required by Laws and Executive Orders, continued
We will also use the information collected on this form to produce summary reports for program and management
analysis, as required by law.
PLEASE NOTE: The estimated burden for completing this form is 1.25 hours. Your responses to the requested
information are required in order to obtain a benefit under SBA’s Disaster Business Loan Programs. However,
you are not required to respond to 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 U.S. Small Business Administration Records Management Division, 409
3RD St., SW, Washington, DC 20416 and Desk Officer for SBA, Office of Management and Budget, Office of
Information and Regulatory Affairs, 725 17TH St., NW, Washington, DC 20503. (3245-0017)
PLEASE DO NOT SEND FORMS TO OMB.
POLICY CONCERNING REPRESENTATIVES AND THEIR FEES
When you apply for an SBA loan, you may use an attorney, accountant, engineer, appraiser, or other representative
to help prepare and present the application to us. You are not required to have representation. If an application is
approved, you may need an attorney to help prepare closing documents.
There are no “authorized representatives” of SBA, other than our employees. Payment of a fee or gratuity to our
employees is illegal and will subject those involved to prosecution.
SBA regulations prohibit representatives from proposing or charging any fee for services performed in connection
with your loan unless we consider the services necessary and the amount reasonable. The regulations also
prohibit charging you any commitment, bonus, broker, commission, referral, or similar fee. We will not approve
the payment of any bonus, brokerage fee, or commission. Also, we will not approve placement or finder’s fees for
using or trying to use influence in the SBA loan application process.
Fees to representatives must be reasonable for services provided in connection with the application or the closing
and based upon the time and effort required, the qualifications of the representative, and the nature and extent of
work performed. Representatives must execute a compensation agreement.
In the appropriate section of the application, you must state the names of everyone employed by you or on your
behalf to complete this loan application. You must also notify the SBA disaster office in writing of the names and
fees of any representative you employ after you file your application.
If you have any questions concerning payment of fees or reasonableness of fees, contact the Field Office where
you filed or will file your application or call the SBA Customer Service Center at 1-800-659-2955.
OCCUPATIONAL SAFETY AND HEALTH ACT (29 U.S.C. 3651 et seq.)
This legislation authorizes the Occupational Safety and Health Administration (OSHA) in the Department of Labor
to require businesses to modify facilities and procedures to protect employees when appropriate.
If your business does not do so, you may be penalized, forced to close, or prevented from starting operations in a
new facility. Because of this, we may require information from you to determine whether your business complies
with OSHA regulations and may continue operating after the loan is approved or disbursed.
You must certify to us that OSHA requirements applying to your business have been determined and that you are,
to the best of your knowledge, in compliance.
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| File Type | application/pdf |
| File Title | Certification of Vaccination |
| File Modified | 2023-05-16 |
| File Created | 2023-05-01 |