SSBCI Reporting Guidance Revised 2022-05-24

U.S. Department of the Treasury
State Small Business Credit Initiative
Capital Program Reporting Guidance
Revised May 24, 20221
Section I. Overview
The American Rescue Plan Act of 2021 (ARPA) reauthorized and amended the Small Business
Jobs Act of 2010, codified at 12 U.S.C. § 5701 et seq., to provide $10 billion to fund the State
Small Business Credit Initiative (SSBCI) as a response to the economic effects of the COVID-19
pandemic. SSBCI is a federal program administered by the Department of the Treasury
(Treasury) that was created to strengthen capital programs that support private financing to small
businesses, including capital access programs (CAPs) and other credit support programs
(OCSPs), of eligible jurisdictions (i.e., states, the District of Columbia, territories, Tribal
governments, and eligible municipalities).
This Capital Program Reporting Guidance details the reporting and document retention
requirements for jurisdictions that receive SSBCI funding (“participating jurisdictions”).
Treasury will create an online portal that participating jurisdictions must use to submit reporting
data. Treasury will provide more information about the submission format in the coming months.
This guidance may be updated periodically. Guidance regarding information that must be
submitted at the end of the SSBCI program will be issued in the future. Furthermore, to increase
the quality and comparability of the demographic data collected, Treasury has published a
sample demographic data collection form that we encourage SSBCI program providers to use.
Section II specifies the deadlines for participating jurisdictions to submit quarterly and annual
reports. Section III sets forth definitions of terms used in this guidance. Sections IV and V
provide details regarding the information to be reported in quarterly and annual reports, which
will support SSBCI implementation, monitoring, and compliance, as well as the assessment of
outcomes of SSBCI-supported investments and loans. Section VI specifies additional
requirements related to record retention and the frequency of reporting.
Treasury may release public reports or data based on the information reported. In any public
report or data, Treasury will, subject to applicable laws and regulations, withhold information
that appears to be personally identifiable information (PII) and sensitive information such as
commercial or financial information about businesses.
Each participating jurisdiction is responsible for the implementation of its SSBCI programs that
have been approved by Treasury (“approved programs”) in accordance with applicable legal,
regulatory, and program requirements, including those in the SSBCI statute and Treasury’s
1

Capital Program Reporting Guidance was initially released on May 9, 2022. It was updated on May 24, 2022 to
provide guidance on a required Privacy Notice and Privacy Act Statement, make technical corrections to Tables 1, 3,
and 7, clarify that Social Security numbers should not be reported as business EINs, provide a Sample Form for
Demographics-Related Data, and reflect Paperwork Reduction Act approval.

1

SSBCI regulations and guidance. Each participating jurisdiction must submit a certification,
using the form in Appendix 1, with every quarterly or annual report, certifying that the
information reported is accurate and that the approved programs of the participating jurisdiction
are being implemented in accordance with applicable legal, regulatory, and compliance
requirements.
Section II. Reporting Deadlines
a. Quarterly Reports
Each participating jurisdiction must submit to Treasury a quarterly report for the first full
calendar quarter following the execution of its Allocation Agreement with Treasury and each
quarter thereafter. Quarterly reports must be submitted within 30 days after the end of each
quarterly reporting period (excluding the quarterly reporting period ending on the expiration date
of the Allocation Agreement). Table 1 provides the submission deadlines for the specified
reporting periods. The requirement to submit quarterly reports will terminate on the first March
31 to occur after five complete 12-month periods after the jurisdiction is approved by Treasury to
be a participating jurisdiction. Under current law, the last quarterly report is due January 30,
2028; however, if the reporting requirement is extended by a future federal statute, then the
extended expiration date shall automatically apply without further action by Treasury.
Table 1. Quarterly Report Deadlines
Reporting Period
July 1, 2022 to September 30, 2022
October 1, 2022 to December 31, 2023
January 1, 2023 to March 31, 2023
April 1, 2023 to June 30, 2023
July 1, 2023 to September 30, 2023
October 1, 2023 to December 31, 2023
January 1, 2024 to March 31, 2024
April 1, 2024 to June 30, 2024
July 1, 2024 to September 30, 2024
October 1, 2024 to December 31, 2024
January 1, 2025 to March 31, 2025
April 1, 2025 to June 30, 2025
July 1, 2025 to September 30, 2025
October 1, 2025 to December 31, 2025
January 1, 2026 to March 31, 2026
April 1, 2026 to June 30, 2026
July 1, 2026 to September 30, 2026
October 1, 2026 to December 31, 2026
January 1, 2027 to March 31, 2027
April 1, 2027 to June 30, 2027
July 1, 2027 to September 30, 2027

Submission Deadline
October 30, 2022
January 30, 2023
April 30, 2023
July 30, 2023
October 30, 2023
January 30, 2024
April 30, 2024
July 30, 2024
October 30, 2024
January 30, 2025
April 30, 2025
July 30, 2025
October 30, 2025
January 30, 2026
April 30, 2026
July 30, 2026
October 30, 2026
January 30, 2027
April 30, 2027
July 30, 2027
October 30, 2027
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Reporting Period
October 1, 2027 to December 31, 2027

Submission Deadline
January 30, 2028

b. Annual Reports
Starting in 2023, each participating jurisdiction must submit to Treasury an annual report for
each calendar year by March 31 of the following year. Table 2 provides the submission deadlines
for the specified reporting periods. The requirement to submit annual reports will terminate on
the first March 31 to occur after five complete 12-month periods after the jurisdiction is
approved by Treasury to be a participating jurisdiction. If the reporting requirement is extended
beyond the initial expiration date by a future federal statute, then the extended expiration date
shall automatically apply without further action by Treasury.
Table 2. Annual Report Deadlines
Reporting Period
January 1, 2022 to December 31, 2022
January 1, 2023 to December 31, 2023
January 1, 2024 to December 31, 2024
January 1, 2025 to December 31, 2025
January 1, 2026 to December 31, 2026
January 1, 2027 to December 31, 2027

Submission Deadline
March 31, 2023
March 31, 2024
March 31, 2025
March 31, 2026
March 31, 2027
March 31, 2028

Section III. Definitions
The following definitions apply in this Reporting Guidance.
Administrative costs. As discussed in Section XI of the SSBCI Capital Program Policy
Guidelines,2 SSBCI administrative costs are defined and governed by the Cost Principles of the
OMB Administrative Requirements, Cost Principles, and Audit Requirements for Federal
Awards (see Subpart E of 2 C.F.R. Part 200). The Cost Principles contain criteria that must be
used to establish chargeable administrative costs and specific information on allowable costs in
various cost categories. Pursuant to 2 C.F.R. § 200.405, administrative costs may be direct or
indirect.
Allocated funds. All the federal funds that are awarded to the participating jurisdiction pursuant
to 12 U.S.C. § 5702.
Contracted entity. An entity that has a contractual arrangement (including through a
memorandum of understanding or other agreement) with the participating jurisdiction or the
participating jurisdiction’s implementing entity for the implementation or administration of its
capital program. This entity may be an authorized agent of the participating jurisdiction
(including an entity or agency of the participating jurisdiction), or an entity selected and
supervised by the participating jurisdiction (including an entity of another jurisdiction, a
2

Available at https://home.treasury.gov/system/files/256/SSBCI-Capital-Program-Policy-Guidelines-November2021.pdf.

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nonprofit third-party, or a for-profit third-party such as an investment fund or loan fund). The
contracted entity may be the entity that operates the SSBCI program.
Controlling influence over a business. Having the power to control, manage, or direct the
business. A person is presumed to have a controlling influence over a business if the person is a
senior executive officer or senior manager of the business (e.g., Chief Executive Officer, Chief
Financial Officer, Chief Operating Officer), or any other individual who regularly performs
similar functions.
Costs of program services. This is the costs of the services provided to a business that are
discussed in Section VIII.i of the Capital Program Policy Guidelines under “Services to Portfolio
Companies.”
Expended, obligated, or transferred. Funds are considered “expended” if the expenses have
been paid by, or are for, an approved state program. Examples of expended funds include:
SSBCI funds that have been disbursed to a lender to cover the federal contribution to a CAP
reserve fund; SSBCI funds that have been disbursed to a specific borrower (or disbursed to a
specific lender as part of a commitment to a specific transaction) as part of a loan participation,
collateral support, or direct lending program; SSBCI funds that have been invested in specific
small businesses pursuant to a venture capital investment; and SSBCI funds that have been spent
for allowable administrative expenses. Funds are considered “obligated” if they have been
committed in writing to pay for the amounts of orders placed, contracts awarded, goods and
services received, and similar transactions during a given period that will require payment by the
approved state program during the same or a future period. Examples of obligated funds include:
SSBCI funds that have been committed, pledged, or otherwise promised, in writing, to a specific
borrower as part of a loan participation, collateral support, or direct lending program; SSBCI
funds that have been set aside to cover obligations arising from loan guarantees; SSBCI funds
that have been committed, pledged, or otherwise promised, in writing, as part of a venture capital
investment transaction; and SSBCI funds that have been committed, pledged, or promised, in
writing, for allowable administrative expenses (e.g., an executed contract for services). Funds are
considered “transferred” if they have been transferred by the state receiving SSBCI funds to the
implementing entity, or the contracted entity, that is charged with administering the day-to-day
operations of the SSBCI program, as a reimbursement for actual expenses or when there is a
clearly documented actual and immediate cash need to fund a loan or investment to an eligible
small business or to pay for allowable administrative expenses.
Financial institution. Any insured depository institution, insured credit union, or community
development financial institution, as those terms are defined in section 103 of the Riegle
Community Development and Regulatory Improvement Act of 1994 (12 U.S.C. § 4702).
Implementing entity. The specific department, agency, or political subdivision of the
participating jurisdiction that has been designated to accept the SSBCI allocation on behalf of the
participating jurisdiction. The term “agency” includes government corporations and other entities
authorized or supervised by the participating jurisdiction. The implementing entity may be the
entity that operates the SSBCI program.

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Minority individual. A natural person who identifies as American Indian or Alaska Native;
Asian American; Black or African American; Native Hawaiian or Other Pacific Islander;
Hispanic or Latino/a; or one or more than one of these groups.
Minority-owned or controlled business. A business that:
(1) if privately owned, 51 percent or more is owned by minority individuals;
(2) if publicly owned, 51 percent or more of the stock is owned by minority individuals;
(3) in the case of a mutual institution, a majority of the board of directors, account holders, and
the community which the institution services is predominantly comprised of minority
individuals; or
(4) one or more minority individuals have the power to exercise a controlling influence over the
business.
Principal owner. A natural person who directly or indirectly, through any contract, arrangement,
understanding, relationship or otherwise, owns 25 percent or more of the equity of the business.
If a trust owns, directly or indirectly, through any contract, arrangement, understanding,
relationship or otherwise, 25 percent or more of the equity interests of the business, the trustee is
a principal owner.
Program income. This is gross income received by the participating jurisdiction that is directly
generated by an SSBCI-supported activity or earned as a result of an SSBCI allocation during the
SSBCI program period. Program income includes, but is not limited to, income from: fees for
services performed that were funded or supported with SSBCI funds, interest earned on loans
made using SSBCI funds, interest on SSBCI funds not invested or lent to a business, and returns
on SSBCI-supported equity investments. Program income does not include repayment of
principal or return of invested capital.
Provider. The entity that transacts directly with the business by making a loan or investment
supported by an approved SSBCI program. For loan programs (e.g., loan participation, loan
guarantee, and collateral support programs; CAPS; and programs involving other credit support),
the provider is the lender whose loan is supported by SSBCI funds. For fund investment
programs, the provider is the fund that invests SSBCI funds and private capital in a business. For
direct investment programs, the provider is the implementing entity or contracted entity that
invests SSBCI funds in a business.
Recycled funds. Funds that (1) come to the participating jurisdiction in the form of program
income, returned program services costs, repayment of principal, or return of invested capital
(i.e., funds that have been previously loaned or invested), and (2) are expended, obligated, or
transferred by the participating jurisdiction on new loans, investments, or other credit equity
support.
SEDI demographics-related business. A business that certifies that it is owned and controlled by
individuals who have had their access to credit on reasonable terms diminished compared to
others in comparable economic circumstances, due to their (1) membership of a group that has
been subjected to racial or ethnic prejudice or cultural bias within American society, (2) gender,
(3) veteran status, (4) limited English proficiency, (5) disability, (6) long-term residence in an
environment isolated from the mainstream of American society, (7) membership of a Federally
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or state-recognized Indian Tribe, (8) long-term residence in a rural community, (9) residence in a
U.S. territory, (10) residence in a community undergoing economic transitions (including
communities impacted by the shift towards a net-zero economy or deindustrialization), or (11)
membership of an “underserved community.” Underserved communities are populations sharing
a particular characteristic, as well as geographic communities, that have been systematically
denied a full opportunity to participate in aspects of economic, social, and civic life, as
exemplified by the list in the definition of equity. Equity is the consistent and systematic fair,
just, and impartial treatment of all individuals, including individuals who belong to underserved
communities that have been denied such treatment, such as Black, Latino, and Indigenous and
Native American persons, Asian Americans and Pacific Islanders and other persons of color;
members of religious minorities; lesbian, gay, bisexual, transgender, and queer (LGBTQ+)
persons; persons with disabilities; persons who live in rural areas; and persons otherwise
adversely affected by persistent poverty or inequality. For purposes of this definition, a business
is “owned and controlled” by applicable individuals:
(1) If privately owned, 51 percent or more is owned by such individuals;
(2) If publicly owned, 51 percent more or of the stock is owned by such individuals; and
(3) In the case of a mutual institution, if a majority of the board of directors, account holders, and
the community which the institution services is predominantly comprised of such individuals.
SSBCI funds. The sum of allocated funds and recycled funds.
Veteran-owned or controlled business. A business that:
(1) if privately owned, 51 percent or more is owned by veterans;
(2) if publicly owned, 51 percent or more of the stock is owned by veterans;
(3) in the case of a mutual institution, a majority of the board of directors, account holders, and
the community which the institution services is predominantly comprised of veterans; or
(4) one or more individuals who are veterans have the power to exercise a controlling influence
over the business.
Women-owned or controlled business. A business that:
(1) if privately owned, 51 percent or more is owned by females;
(2) if publicly owned, 51 percent or more of the stock is owned by females;
(3) in the case of a mutual institution, a majority of the board of directors, account holders, and
the community which the institution services is predominantly comprised of females; or
(4) one or more individuals who are females have the power to exercise a controlling influence
over the business.
Section IV. Quarterly Reporting
As described below, participating jurisdictions must provide two categories of information in the
quarterly reports: (1) basic program information and (2) program-level information on the use of
SSBCI funds.

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a. Basic Program Information in Quarterly Reports
For each of the participating jurisdiction’s approved SSBCI programs, the participating
jurisdiction must provide the information listed in Table 3.
Table 3. Basic Program Information in Quarterly Reports
Data Element
Approved Program Name
Program Type

Primary Program
Administrator

Description
Confirm the name of each approved program.
Confirm the program type of each approved program, as one of the
following:
-Credit – Loan participation program
-Credit – Loan guarantee program
-Credit – Collateral support program
-Credit – Capital access program
-Credit – Debt fund investment program
-Credit – Other support program
-Equity – Fund investment program
-Equity – Direct investment program
-Equity – Other support program
-Hybrid – Other support program
Confirm the name of the entity primarily responsible for
administering each approved program.

b. Program-Level Information on the Use of SSBCI Funds in Quarterly Reports
For each of the participating jurisdiction’s approved SSBCI programs, the participating
jurisdiction must provide the information listed in Table 4. The participating jurisdiction should
provide additional descriptions as needed to help Treasury understand the reported information.
Table 4. Program-Level Information on the Use of SSBCI Funds in Quarterly Reports
Data Element

Description

Approved Program Name

Select the name of each approved program.

Program Total Allocated
Funds Expended, Obligated,
or Transferred (EOT)
Program Allocated Funds
EOT for Direct
Administrative Costs
Program Allocated Funds
EOT for Indirect
Administrative Costs

Dollar amount of allocated funds EOT.

Dollar amount of allocated funds EOT for direct administrative
costs.
Dollar amount of allocated funds EOT for indirect administrative
costs.

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Data Element

Description

Program Total Recycled
Funds EOT
Contracted Entity Funding

Dollar amount of recycled funds EOT.

Program Income
CAP Charge-offs

Dollar amount of SSBCI funds budgeted by
the participating jurisdiction to each contracted entity.
Dollar amount of program income earned.
Dollar amount of SSBCI funds used for charge-offs against federal
contributions to CAP reserve funds.

This field only appears if the
program is a CAP.
Additional Information
Text field for any additional clarifications, descriptions, or
information.
Section V. Annual Reporting
Participating jurisdictions must provide various categories of information in annual reports.
Table 5 indicates the frequency of reporting for each category.
Table 5. Annual Report Information and Frequency
Category of Information Reporting Frequency
Providers in an approved
Data only must be reported one time for each provider (unless
program (see Table 6 below) there are updates to previously reported information), except that
allocated funds expended for costs of program services must be
reported on an annual basis.
Transactions (see Table 7
Data must be reported only one time for each SSBCI-supported
below)
loan or investment.
Transaction terms (see
Data must be reported only one time for each SSBCI-supported
Tables 8 and 9 below)
loan or investment.
Loan or investment
Data must be reported annually for each SSBCI-supported loan
performance (see Table 10 or investment, if applicable.
below)
Borrower/Investee Data (see Data should be reported annually after the closing of each SSBCITable 11 below)
supported loan or investment, if available.
In addition, each participating jurisdiction must provide a concise narrative for each approved
program containing program-level updates on the progress the participating jurisdiction made on
the plan it submitted with its SSBCI application on how the participating jurisdiction would use
the federal contribution to the approved program to help provide access to capital for small
businesses in underserved communities.3 The participating jurisdiction must also include any
updates regarding the anticipated benefits to the jurisdiction from the approved program that
were previously described in its application.4 Finally, the participating jurisdiction must provide

3
4

For more information on this requirement, see Section IX.a of the Capital Program Policy Guidelines.
For more information on this requirement, see Section VIII.g of the Capital Program Policy Guidelines.

8

an annual update of how the participating jurisdiction intends to apportion its allocation among
its approved programs.
a. Information about Providers in an Approved Program
Table 6 lists the data elements that the participating jurisdiction must report for each
provider in an approved program. All data elements in Table 6, except for allocated funds
expended for costs of program services (the last item listed in Table 6), only need to
be reported once and then updated in subsequent annual reports only if there are changes.
Table 6. Data Elements for Each Provider in an Approved Program5
Data Element
Approved Program Name
Provider
Provider EIN

Description
Select the name of each approved program.
Enter the name of the provider.
Provider’s employer identification number (EIN) or tax ID
number.

5

Note that an entity that is a provider may participate in more than one program of a participating jurisdiction or in
programs of two or more participating jurisdictions. Examples might include lenders that participate both in a
jurisdiction’s loan participation program and the jurisdiction’s loan guarantee program, or a venture capital fund that
participates in programs of two different jurisdictions. In these cases, the entity (in these examples, the lender or
venture capital fund) would have multiple provider records, one for each approved program of a participating
jurisdiction that the entity serves as a provider.

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Data Element
Provider Regulatory ID

Description
For providers whose deposits are insured by the Federal Deposit
Insurance Corporation (FDIC), provide the provider’s RSSD ID.
For federally insured credit unions, provide the provider’s charter
number from the National Credit Union Administration (NCUA).
For Community Development Financial Institutions (CDFIs),
provide the provider’s CDFI certification number.
For fund managers registered as investment advisers with the
Securities and Exchange Commission (SEC), provide the
provider’s SEC registration number.
For fund managers registered with the jurisdiction itself,
provide the provider’s registration number from the jurisdiction.
If none of the above regulatory IDs apply, but another regulatory
ID applies, respond “Other.”
If no regulatory ID number applies, respond “None.”

Other Provider ID

If a provider has multiple regulatory IDs, the participating
jurisdiction must provide at least one of these regulatory IDs and
may provide additional regulatory IDs.
Text field for a description if the participating jurisdiction
responded “Other” for the data element “Provider Regulatory ID.”

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Data Element
Provider Type

Description
Indicate what type of entity the provider is (if multiple types apply,
choose the one that best describes the provider’s role in the
program):
-CDFI bank, thrift, credit union, or depository institution holding
company
-Non-CDFI community bank
-Other bank, thrift, or depository institution holding company
-CDFI loan fund
-Non-CDFI credit union
-Nonbank lender or nonbank payment services provider
-Non-CDFI debt or loan fund
-Growth equity capital fund
-Angel investor or angel fund
-Accelerator or incubator fund
-For-profit venture capital fund
-Nonprofit venture capital fund or venture/entrepreneurial
development organization
-Corporate venture capital fund
-CDFI venture capital fund
-University/technology transfer office
-Other
Other Provider Type
Text field for a description if the participating jurisdiction
responded “Other” for the data element “Provider Type.”
Minority Depository
Indicate whether the provider is a Minority Depository Institution.
Institution
-Yes
-No
Fund as Source of Private
Indicate whether the provider is a fund that is the primary source
Capital
of private capital for the purpose of meeting the 1:1 financing
requirement as described in Section VIII.c of the Capital Program
Policy Guidelines.
-Yes
-No
Provider as Source of Private If the provider is not a fund, indicate whether the provider is the
Capital
primary source of private capital for the purpose of meeting the 1:1
financing requirement as described in Section VIII.c of the Capital
Program Policy Guidelines.
-Yes
-No
Target Fund Size
If the provider is a fund, provide the target total fund
size including SSBCI funds and other capital.

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Data Element
Incubation and Early-Stage
Investment Call Option

Allocated Funds Expended
for Costs of Program
Services

Description
If the provider is an equity program, indicate whether a call option
is offered under the Incubation or Early-Stage Investment Model
described in Section VIII.i of the Capital Program Policy
Guidelines.
-Yes
-No
If the provider is a venture capital fund, specify the annual dollar
amount of allocated funds expended by the fund for services to
portfolio companies. This data element is reported on an annual
basis.

b. SSBCI-Supported Loan and Investment Information
Table 7 lists the data elements that the participating jurisdiction must report for each SSBCIsupported loan or investment. Table 7 includes, among other items, demographics-related
information satisfying the requirements in the SSBCI Interim Final Rule.6 Tables 8 and 9 list
data elements on transaction terms for credit programs and equity programs, respectively.
Each participating jurisdiction must report the data elements in Table 7 and in either Table 8 or 9
for each SSBCI-supported loan or investment that received a disbursement from the provider to
the business during the applicable annual reporting period. All data elements in Tables 7, 8, and
9 only need to be reported once. Participating jurisdictions must provide a Privacy Notice and
Privacy Act Statement (see Appendix 2) to those from whom they collect data, or cause the
entities that collect this data directly to do the same.
The demographics-related data elements may only be collected and used for purposes of the
SSBCI program and must not be used for any other purposes (e.g., marketing, sale to thirdparties). The demographics-related information must not be used in a manner that violates any
applicable anti-discrimination laws, including, but not limited to, the laws specified in Section
IX.b of the Capital Program Policy Guidelines (Compliance with Civil Rights Requirements).
Participating jurisdictions must establish processes to inform small businesses of this limited
usage when these data elements are collected. Each participating jurisdiction shall establish data
privacy and security requirements for the demographic-related information described in Table 7
that include appropriate measures to ensure that the privacy of the individuals is
protected. SSBCI is providing a sample demographic data collection form that can be used to
collect these data elements, with instructions for how the sample form should be used (see
Appendix 3). This sample form will be a useful tool for participating jurisdictions.
Table 7. SSBCI-Supported Loan and Investment Information for All Programs
Data Element
Provider

Definition
Select name of the provider.

6

State Small Business Credit Initiative; Demographics-Related Reporting Requirements, Department of the
Treasury, 87 Federal Register 13628 (March 10, 2022).

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Data Element
Approved Program Name
Unique Transaction ID
Business Name
Business EIN

Definition
Select the name of the approved program.
Alphanumeric or numeric code that is unique to each transaction.
Name of the borrower or investee.
EIN of the borrower or investee.

Do not provide a business EIN if it is a Social Security number.
Business Street Address
Street address of the borrower or investee’s main office or location
of the borrower or investee that is primarily benefitting from the
SSBCI funds. If real estate construction financing is
involved, enter the street address of the project.
Business City
City of the borrower or investee.
Business State
State of the borrower or investee.
Business Zip Code
Zip code of the borrower or investee.
NAICS Code
2017 North American Industry Classification System (NAICS)
codes for the borrower’s or investee’s industry.
Year Business Opened
Year in which the borrower or investee commenced operations.
Form of Business
Legal entity type of the borrower or investee:
Organization
-Any organizational form that is a nonprofit entity
-Sole proprietor/independent contractor
-Partnership
-Limited liability company
-Corporation
-Worker cooperative or other employee-owned entity
-Tribal enterprise
-Tribal member-owned business
-Other
Other Type of Business
Text field for a description if selected “Other” in the data element
Receiving SSBCI Funds
“Form of Business Organization.”
Tribal Government Program Type of Tribal government program transaction. Select all that
Transaction Type
apply:
-In-jurisdiction transaction with business on Tribal lands
This field only appears if the -In-jurisdiction transaction with business in states where the Tribe
participating jurisdiction is a is physically located or within which the Tribe exercises
Tribal government.
jurisdiction
-In-jurisdiction transaction with Tribal enterprise-operated
business, business owned by Tribal members, or business in a state
in which Tribal members reside
-Out-of-jurisdiction transaction – Transaction that does not fit into
any of the categories above

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Data Element
Definition
Primary Transaction Source Indicate the primary source of private capital to the business for
of Private Capital
the purpose of meeting the 1:1 financing requirement as described
in Section VIII.c of the Capital Program Policy Guidelines:
This field only appears if
-CDFI bank, thrift, credit union, or depository institution holding
response was “No” to both company
data element “Fund as
-Non-CDFI Community bank
Source of Private Capital” -Other bank, thrift, or depository institution holding company
and to “Provider as Source of -CDFI loan fund
Private Capital” in Table 6. -Non-CDFI credit union
-Nonbank lender or nonbank payment services provider
-Non-CDFI debt or loan fund
-Growth equity capital fund
-Angel investor or angel fund
-Accelerator or incubator fund
-For-profit venture capital fund
-Nonprofit venture capital fund or venture/entrepreneurial
development organization
-Corporate venture capital fund
-CDFI venture capital fund
-Tribal enterprise new funds
-Other for-profit investor
-Other non-profit investor

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Data Element
Secondary Transaction
Source of Private Capital

Definition
Indicate the secondary sources of private capital to the business for
the purpose of meeting the 1:1 financing requirement as described
in Section VIII.c of the Capital Program Policy Guidelines. Select
This field only appears if
all that apply:
response was “No” to both -CDFI bank, thrift, credit union, or depository institution holding
“Fund as Source of Private company
Capital” and to “Provider as -Community bank
Source of Private Capital.” -Non-CDFI bank, thrift, or depository institution holding
company
-CDFI loan fund
-Non-CDFI credit union
-Nonbank lender or nonbank payment services provider
- Non-CDFI debt or loan fund
-Growth equity capital fund
-Angel investor or angel fund
-Accelerator or incubator fund
-For-profit venture capital fund
-Nonprofit venture capital fund or venture/entrepreneurial
development organization
-Corporate venture capital fund
-CDFI venture capital fund
-Tribal enterprise new funds
-Other for-profit investor
-Other non-profit investor

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Data Element
Definition
Primary Purpose of the Loan Indicate the primary purpose of the SSBCI-supported loan or
or Investment
investment that the borrower or investee obtained:
-Marketing, market research, and commercialization expenses
-Research and development
-Technology integration in physical production, e.g.,
manufacturing or supply chain
-Technology integration of nonphysical production, e.g.,
accounting, customers
-Acquire land
-Purchase existing building
-Convert, expand, or renovate buildings – energy efficiency
-Convert, expand, or renovate buildings – other
-Construct new buildings
-Acquire and install fixed assets
-Acquire inventory
-Purchase supplies and raw materials
-Leasehold improvements
-Working capital – wages, salaries, and benefits of employees
-Working capital – other
-Refinance outstanding debt
-Support employee stock ownership plan (ESOP) transactions
-Other
Purpose of the Loan or
Text field for description if selected “Other” in the data element
Investment – Other
“Primary Purpose of the Loan or Investment.”

16

Data Element
Secondary Purpose of the
Loan or Investment

Definition
Indicate the secondary purpose of the SSBCI-supported loan or
investment that the borrower or investee obtained. Select all that
apply:
-Marketing, market research, and commercialization expenses
-Research and development
-Technology integration in physical production, e.g.,
manufacturing or supply chain
-Technology integration of nonphysical production, e.g.,
accounting, customers
-Acquire land
-Purchase existing building
-Convert, expand, or renovate buildings – energy efficiency
-Convert, expand, or renovate buildings – other
-Construct new buildings
-Acquire and install fixed assets
-Acquire inventory
-Purchase supplies and raw materials
-Leasehold improvements
-Working capital – wages, salaries, and benefits of employees
-Working capital – other
-Refinance outstanding debt
-Support employee stock ownership plan (ESOP) transactions
-Other
Secondary Purpose of the
Text field for description if selected “Other” in the data element
Loan or Investment – Other “Secondary Purpose of the Loan or Investment.”
Climate-aligned Investment Indicate whether the SSBCI-supported loan or investment supports
a business that makes climate-aligned investments. Climatealigned investments may reduce greenhouse gas emissions or
promote adaptation to climate change or energy transitions. This
could be either in the business’s activities (including its production
processes and use of energy, inputs, supply chain services, and/or
actions to increase resiliency) or by supplying products and
services that contribute to lower emissions. Climate-aligned
investments can include investment supporting weatherization;
energy-efficient prefabrication or manufacturing; supply chain use,
processes or production resulting in lower emissions; energy site
transitions; sustainable and/or climate-smart agriculture and
forestry; renewable energy development or implementation
(including wind, solar, hydroelectric, biomass, geothermal, and
other low-carbon technologies); electric vehicle innovation or use;
and other investments that aim to build climate resilience, support
adaptation to extreme weather and climate events, and/or mitigate
climate change.
-Yes
-No
17

Data Element
Definition
Energy- or Climate-Impacted Indicate whether the SSBCI-supported loan or investment
Communities
supports a small business in a community facing local job losses or
business revenue declines due to physical or transition impacts
from climate change, including shifts in energy production.
Examples of such local job loss or revenue declines include
declines due to changes in the economics of producing certain
agriculture or foods, other natural resource goods, chemical inputs,
manufactured products, or service sector outputs due to acute or
chronic climate impacts, costs, regulations, or shifts in demand.
Examples of shifts in energy production include any transition
away from fossil fuel extraction, refining, or fossil-based energy
generation in the oil, gas, and/or coal sector.
-Yes
-No
Disbursement Date
Date that the funds for the SSBCI-supported loan or
investment were disbursed from the provider to the borrower or
investee.
Loan or Investment
Dollar amount that was disbursed from the provider to the business
Transaction Amount
for the SSBCI-supported loan or investment, including SSBCI
funds and private capital.
Do not include any amounts reported under “Concurrent Private
Financing” that are associated with, but separate from, the SSBCIsupported loan or investment.
Allocated Funds Expended For loan participation programs, dollar amount of allocated funds
or Set Aside for Guarantees expended for the approved program’s participation in the loan.
or Collateral Support
Obligations
For loan guarantee programs, dollar amount of allocated funds set
aside to cover the guarantee amount of commitment.
For collateral support programs, dollar amount of allocated funds
set aside to cover the collateral support obligation.
For CAPs, dollar amount of allocated funds expended as the
approved program’s contribution to the CAP reserve fund.
For direct investment programs, dollar amount of allocated funds
invested directly in a business.
For fund investment programs, dollar amount of allocated funds
invested directly in a business through a fund in which the
participating jurisdiction has invested allocated funds.

18

Data Element
Definition
Recycled Funds Expended or For loan participation programs, dollar amount of recycled funds
Set Aside for Guarantees or expended for the approved program’s participation in the loan.
Collateral Support
Obligations
For loan guarantee programs, dollar amount of recycled funds set
aside to cover the guarantee amount of commitment.
For collateral support programs, dollar amount of recycled funds
set aside to cover the collateral support obligation.
For CAPs, dollar amount of recycled funds expended as the
approved program’s contribution to the CAP reserve fund.
For direct investment programs, dollar amount of recycled funds
invested directly in a business.
For fund investment programs, dollar amount of recycled funds
invested directly in a business through a fund in which the
participating jurisdiction has invested recycled funds.
Additional Government
Dollar amount of other funding from other public or government
Funds
sources invested at the same time as the SSBCI-supported loan or
investment.
Concurrent Private Financing Dollar amount of any private financing that was caused by or
resulted from the SSBCI-supported loan or investment and that
occurred at or around the same time as the SSBCIsupported loan or investment.
Business Revenue
Borrower’s or investee’s annual gross revenues for the fiscal or
calendar year prior to the closing of the loan or investment. This
may be the most recent year for which taxes were filed.
Business Net Income
Borrower’s or investee’s net income for the fiscal or calendar year
prior to the closing of the loan or investment. This may be the
most recent year for which taxes were filed.
Full-Time Equivalent
Borrower’s or investee’s full-time equivalent employees (FTEs),
Employees
rounded to the nearest whole number, at the time of the closing of
the SSBCI-supported loan or investment. This is determined by
adding the number of full-time employees and number of part-time
and seasonal employees as a fraction of a full-time employee.
For example, if a business has 100 employees working full-time
(assume a full-time week of 40 hours) and 50 employees working
20 hours per week, the total number of FTEs would be 125. For
seasonal employees, the FTE count is based on a 2,080-hour year,
so that an employee who works 520 hours per year counts as 0.25
FTEs.

19

Data Element
Expected Jobs Created

Definition
Number of full-time, part-time, and temporary jobs expected to be
created as a direct result of the SSBCI-supported loan or
investment within two years from the date of the loan or
investment closing.
Expected Jobs Retained
Number of full-time, part-time, and temporary job losses averted
as a direct result of the SSBCI-supported loan or investment (not
including jobs that were not at risk of being lost).
Self-certified SEDI Owned Indicate whether the borrower or investee certified that it is owned
and Controlled in CDFI
and controlled by individuals whose residences are in CDFI
Investment Area
Investment Areas.
-Self-certified
-The business did not certify
Self-certified SEDI Future Indicate whether the borrower or investee certified that it will
Location in CDFI Investment operate a future location in a CDFI Investment Area.
Area
-Self-certified
-The business did not certify
SEDI Status by Business
Indicate whether the borrower or investee is located in a CDFI
Address in CDFI Investment Investment Area, as evidenced by the business address.
Area
-Yes
-No
Self-Certified SEDI
Indicate whether the business self-certified that it is a SEDI
Demographics-Related
demographics-related business. Select which one or more of the
Business Status
categories that apply:
-Self-certified due to membership of a group that has been
subjected to racial or ethnic prejudice or cultural bias within
American society
-Self-certified due to gender
-Self-certified due to veteran status
-Self-certified due to limited English proficiency
-Self-certified due to disability
-Self-certified due to long-term residence in an environment
isolated from the mainstream of American society
-Self-certified due to membership of a Federally or staterecognized Indian Tribe
-Self-certified due to long-term residence in a rural community
-Self-certified due to residence in a U.S. territory
-Self-certified due to residence in a community undergoing
economic transitions (including communities impacted by the shift
towards a net-zero economy or deindustrialization)
-Self-certified due to membership of an “underserved community”
as defined in Executive Order 13985 (see the definition of “SEDIowned and controlled business in Section II above)
-The business did not certify

20

Data Element
Minority-Owned or
Controlled Business Status

Women-Owned or
Controlled Business Status

Veteran-Owned or
Controlled Business Status

Race of Principal Owners

Ethnicity of Principal
Owners

Definition
Indicate whether the business is a minority-owned or controlled
business:
-Yes
-No
-Prefer not to respond
-The business did not answer
Indicate whether the business is a women-owned or controlled
business:
-Yes
-No
-Prefer not to respond
-The business did not answer
Indicate whether the business is a veteran-owned or controlled
business:
-Yes
-No
-Prefer not to respond
-The business did not answer
For each principal owner of the business, indicate the one or more
race categories with which the principal owner identifies:
-American Indian or Alaska Native
-Asian
--Indian
--Chinese
--Filipino
--Japanese
--Korean
--Vietnamese
--Asian (Other)
-Black or African American
-Native Hawaiian or Other Pacific Islander
--Guamanian or Chamorro
--Native Hawaiian
--Samoan
--Pacific Islander (Other)
-White
-Prefer not to respond
-The business did not answer
For each principal owner of the business, indicate which of the
following ethnicity categories the principal owner identifies with:
-Hispanic or Latino/a
-Not Hispanic or Latino/a
-Prefer not to respond
-The business did not answer

21

Data Element
Definition
Middle Eastern or North
For each principal owner of the business, indicate which of the
African Ancestry of Principal following ancestry categories the principal owner identifies with:
Owners
-Middle Eastern or North African
-Not Middle Eastern or North African
-Prefer not to respond
-The business did not answer
Gender of Principal Owners For each principal owner of the business, indicate which one of the
following gender categories the principal owner identifies with:
-Female
-Male
-Nonbinary
-Prefer to self-describe
-Prefer not to respond
-The business did not answer
Gender of Principal Owners Text field for description if selected “Prefer to self-describe” in
– Self-Identification
the data element “Gender of Principal Owners.”
Sexual Orientation of
For each principal owner of the business, indicate which one of the
Principal Owners
following sexual orientation categories the principal owner
identifies with:
-Gay or lesbian
-Bisexual
-Straight, that is, not gay, lesbian, or bisexual
-Something else
-Prefer not to respond
-The business did not answer
Veteran Status of Principal For each principal owner of the business, indicate which of the
Owners
following categories the principal owner identifies with:
-Veteran
-Non-veteran
-Prefer not to respond
-The business did not answer
Table 8. Transaction Terms Specific to Credit Programs
Data Element
Unique Transaction ID
Loan Type

Definition
Alphanumeric or numeric code that is unique to each transaction.
Type of loan:
-Term with a specified repayment schedule and a fixed or floating
interest rate
-Revenue-based, income-based, or other performance-contingent
payments
-Line of credit
-Bridge, venture debt or other debt whose repayment is contingent
on event (with or without interim interest payments)
-Other
22

Data Element
Other Loan Type
Loan Term

Loan APR

Interest Rate Variability

Other Repayment Terms

Maximum Interest Rate
Total Origination Charges

Definition
Text field for description if selected “Other” in the data
element “Loan Type.”
Duration of the loan term in months.
Provide an estimate if repayment depends on the borrower’s
revenue or performance activity.
Annual percentage rate (APR) charged to the borrower. The APR
is the yearly interest calculated from a sum that's charged to
borrowers, including fees.
Variability of interest rate:
-Fixed interest rate
-Adjustable interest rate
-Both a fixed interest rate and an adjustable interest rate
Text field for description of material terms (e.g., percentage of
monthly revenues) if the loan is revenue-based or performancebased.
Maximum interest rate permitted under the loan (not including
fees, penalty interest, or other charges).
Total dollar amount of charges imposed directly or indirectly by
the provider at or before origination as an incident to or a condition
of the extension of credit, including charges paid by the borrower
at or before origination or that are financed. Charges that are
imposed indirectly by the provider include charges by a third party
that may pass through the provider to the borrower or that are
billed separately.

Table 9. Transaction Terms Specific to Equity Programs
Data Element
Unique Transaction ID
Stage of Investment

Definition
Alphanumeric or numeric code that is unique to each transaction.
Stage of the business on the transaction date for all equity
investments:
-Pre-Seed – developing technology or business model for
product/service
-Seed – proof-of-concept and developed business model
-Early Stage – product/service launch and market traction
-Later Stage – scale-up operations and growing revenue
-Growth Equity – mature business seeking growth opportunities
-Other

23

Data Element
Security Type

Definition
Type of security purchased:
-Common stock
-Preferred stock
-Convertible debt (debt with automatic conversion to equity in a
qualified priced round)
-Standard agreement for future equity (SAFE) or other
unpriced equity-like securities
-Other
Other Security Offered
Text field for description if selected “Other” in the data
element “Security Type.”
SSBCI Ownership Percentage For direct investment programs, the percentage of equity
ownership of the business on a fully diluted basis acquired using
This field only appears if
SSBCI funds.
common stock or preferred
stock.
For fund investment programs, the implied percent of equity
ownership of the business on a fully diluted basis that is
calculated, for example by multiplying the percent of the SSBCI
funds investment in an equity fund times the percent of the
business which the equity fund owns after the transaction, or by
some other method.

Conversion Discount

The participating jurisdiction selects one:
-0% to 5%
-5% to 10%
-10% to 20%
-20% to 50%
-Greater than 50%
Percentage reduction on the price of equity shares at
which the convertible note investors’ claim converts to
equity relative to the next qualified priced round.

This field only appears
if convertible note, SAFE or
other unpriced equity-like
securities.
Valuation Cap
Imposed maximum valuation of the business used to price the
SSBCI investment for conversion into equity shares at the next
This field only appears if
qualified priced round.
convertible note, SAFE or
other unpriced equity-like
securities.
Type of Valuation Cap
Indicate whether the valuation cap is pre-money or post-money.
-Pre-money
This field only appears if
-Post-money
convertible note, SAFE or
other unpriced equity-like
securities.
24

c. SSBCI-Supported Loan and Investment Performance Information
Table 10 lists additional data that each participating jurisdiction must report for each SSBCIsupported loan or investment. The data specified in Table 10 must be reported in the annual
report, if applicable, for an SSBCI-supported loan or investment. The purpose of this information
is to understand how the loan or investment performed and affected the business.
As shown in Table 10, subsequent private financing caused by, or resulting from, the initial
SSBCI-supported OCSP financing must be reported. Subsequent financing is considered to be
caused by, or resulting from, the initial SSBCI-supported OCSP financing when such OCSP
financing increases the current and future creditworthiness of a business. This nexus between the
initial SSBCI-supported loan or investment and subsequent private financing occurs only when
such loan or investment is a form of subordinated, mezzanine, or equity financing—in other
words, a form of financing that strengthens the business’s balance sheet. If there is no such
nexus, then no subsequent private financing is reported.
Participating jurisdictions report subsequent private financing until (1) the completion of the
contract, default or business failure, an exit event, or other event that ends the lending or
investment relationship, or (2) the end of the SSBCI program reporting requirements.
Table 10. Information on SSBCI-Supported Loan or Investment Performance
Data Element
Unique Transaction ID
Subsequent Private
Financing
SSBCI Funds Lost

Equity Investment Gains

Definition
Alphanumeric or numeric code that is unique to each transaction.
Total dollar amount of private financing received after closing of
the loan or investment that is caused by, or resulting from, the
initial SSBCI-supported loan or investment.
Dollar amount of SSBCI funds that were lost (by the jurisdiction)
due to loan default or loss of investment (i.e., an investment is
written off).
Dollar amount of any gains returned to the jurisdiction (as the
SSBCI investor/lender) above the amount of invested SSBCI
capital.

Table 11 lists additional data that participating jurisdictions should collect from the borrower or
investee annually after the closing of each SSBCI-supported loan or investment, if available. The
data specified in Table 11 should be reported in each annual report, if available.
Table 11. Borrower/Investee Data
Data Element
Business Revenue

Definition
Borrower’s or investee’s annual gross revenues for its most recent
fiscal or calendar year. This may be the most recent year for which
taxes were filed. There will be an option to report that the
information is not available.

25

Data Element
Business Net Income

Definition
Borrower’s or investee’s net income for its most recent fiscal or
calendar year. This may be the most recent year for which taxes
were filed. There will be an option to report that the information is
not available.
Year of Reported Business Fiscal or calendar year of the data reported for Business Revenue
Revenue and/or Net Income and/or Business Net Income.
Section VI. Record Retention and Increase of Frequency and Scope of Reporting
Before providing funding to a private entity using SSBCI funds, each participating jurisdiction
must obtain the following:
• The written agreement of the private entity, including any financial institution, to make
available to the Treasury Inspector General and the Government Accountability Office all
books and records related to the use of the SSBCI funds, subject to applicable privacy
laws, including but not limited to 12 U.S.C. § 3401 et seq., including detailed loan and
investment records, as applicable;
• A certification from the private entity, if it is a financial institution, that the private entity
is in compliance with the requirements of 31 C.F.R. § 1020.220, regarding customer
identification programs; and
• A certification from the private entity, including any financial institution, that the
principals of such entity have not been convicted of a sex offense against a minor (as
such terms are defined in section 111 of the Sex Offender Registration and Notification
Act (42 U.S.C. 16911)).
Treasury will apply record retention principles that are consistent with the approach set forth in
2 C.F.R. § 200.334. Each participating jurisdiction must retain all financial records, supporting
documents, statistical records, and all other records pertinent to its SSBCI allocation for a period
of three years from the date of submission of the final quarterly report under Section II.a, except
as otherwise provided in 2 C.F.R. § 200.334. Treasury, the Treasury Inspector General, the
Government Accountability Office, or any of their duly authorized representatives have the right
of timely and unrestricted access to any books, documents, papers, or other records of the
participating jurisdiction that are pertinent to the participating jurisdiction’s allocation, in order
to make audits, investigations, examinations, excerpts, transcripts, and copies of such documents.
This right also includes timely and reasonable access to the participating jurisdiction’s personnel
for the purpose of interviews and discussion related to such documents. This right of access will
last as long as records are required to be retained, except that Treasury’s right of access expires
on the date that is 180 days after the end of the period of performance for the participating
jurisdiction’s SSBCI funds.
Treasury may unilaterally increase the frequency and the scope of a participating jurisdiction’s
reporting requirements if Treasury finds the participating jurisdiction to be a high-risk
jurisdiction. To determine whether a participating jurisdiction is a high-risk jurisdiction,
Treasury will apply a risk evaluation approach that is consistent with the principles set forth in
2 C.F.R. § 200.206. Treasury may find a participating jurisdiction to be a high-risk jurisdiction
26

prior to the jurisdiction’s receipt of allocated funds or after the participating jurisdiction receives
its allocated funds.
Because participating jurisdictions and their contracted entities will be receiving sensitive
information, Treasury strongly encourages participating jurisdictions and their contracted entities
to establish robust protections against data breaches and misuse and to comply with all
applicable privacy laws.
Paperwork Reduction Act Notice - OMB Control Number 1505-0227
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a valid control number assigned by OMB.

27

Appendix 1.
Certification Required with SSBCI Quarterly and Annual Reports
The undersigned, on behalf of the participating jurisdiction specified below, hereby makes the
following certifications as of the date of this certification:
1. The information, certifications, attachments, and other information provided by the
participating jurisdiction specified below to the U.S. Department of the Treasury related
to the State Small Business Credit Initiative (SSBCI) are true and correct and do not
contain any materially false, fictitious, or fraudulent statement, nor any concealment or
omission of any material fact;
2. SSBCI funds continue to be available and legally committed to contributions by
the participating jurisdiction to, or for the account of, approved programs, less any
amount that has already been contributed by the participating jurisdiction to, or for the
account of, approved programs subsequent to the participating jurisdiction being
approved for participation in the SSBCI;
3. The participating jurisdiction is implementing its approved SSBCI program or programs
in accordance with all applicable legal, regulatory, and program requirements,
including the SSBCI statute (12 U.S.C. § 5701 et seq.) and the U.S. Department of
the Treasury’s SSBCI regulations and guidance to the best of the undersigned’s
knowledge; and
4. The undersigned has authority to execute and deliver this certification on behalf of
the participating jurisdiction.
IN WITNESS WHEREOF, this certificate has been duly executed and delivered as of
the [ ] day of [ ], 202[ ].

[Name of Participating Jurisdiction]
By: _______________________________
Name:
Title:

Appendix 2.
SSBCI Privacy Notice and Privacy Act Statement
Privacy Notice:
Information from this collection will be shared with the U.S. Department of the Treasury
(Treasury). Treasury has published a Privacy and Civil Liberties Impact Assessment that
describes what Treasury will do with the information your business provides in this application.
It can be found on the Treasury website. If you have any questions about this document, please
email Privacy@Treasury.gov.
Privacy Act Statement for Sole Proprietorships:
The Privacy Act of 1974 (Privacy Act) protects certain information that the federal government
has about “individuals” (United States citizens and lawfully admitted permanent residents). The
Privacy Act does not generally apply to businesses, but some federal courts have found that this
law applies to sole proprietors (they are deemed “individuals” under the Privacy Act). If you, as
the applicant, are a sole proprietor, you may have rights under the Privacy Act.
Authority: Small Business Jobs Act of 2010 (SBJA), Title III, 12 U.S.C. § 5701 et seq., as
amended by the American Rescue Plan Act of 2021 (ARPA), section 3301; Executive Order No.
13985, Advancing Racial Equity and Support for Underserved Communities Through the
Federal Government, 86 Fed. Reg. 7009 (January 25, 2021); and Interim Final Rule, State Small
Business Credit Initiative; Demographics-Related Reporting Requirements, 87 Fed. Reg. 13628
(March 10, 2022).
Purpose: Information from this collection will be shared with Treasury. This information will be
shared with Treasury so it can conduct oversight to ensure compliance with federal law,
including requirements related to nondiscrimination and nondiscriminatory uses of federal funds.
Treasury also receives this information (including any demographic information provided) to
comply with reporting requirements under the authorities listed above and to advance fairness
and opportunity in underserved communities in the allocation of federal resources.
Routine Uses: The information you furnish may be shared in accordance with the routine uses
outlined in Treasury .013, Department of the Treasury Civil Rights Complaints and Compliance
Review Files; Treasury .015, General Information Technology Access Account Records; and
Treasury .017, Correspondence and Contact Information. For example, one routine use under
Treasury .013 is to disclose pertinent information to appropriate agencies when Treasury
becomes aware of a potential violation of civil or criminal law. Under this routine use, Treasury
may disclose demographic information to the appropriate agencies if Treasury becomes aware of
a violation of applicable antidiscrimination laws. More information about this and other routine
uses can be found in the System of Records Notices (SORNs) listed above, which are posted on
Treasury’s website.
Disclosure: Providing this information is voluntary. However, failure to furnish the requested
information (except for the demographic information) may result in the denial of your
application. Providing demographic information is optional. If you decline to provide this
information, it will not adversely affect your application.

Appendix 3.
SSBCI Sample Form for Demographics-Related Data
This sample form may be used by a participating jurisdiction and/or its providers to obtain
demographics-related data. This sample form is provided for illustrative purposes as a tool for
participating jurisdictions. Participating jurisdictions may adopt their own form, provided that it
complies with all SSBCI requirements.
Legal name of borrower or investee: __________________________________________
This transaction is supported with funding provided through the State Small Business Credit
Initiative (SSBCI), a federal program that supports small business lending and investment
programs in states, the District of Columbia, territories, and Tribal governments (collectively,
“participating jurisdictions”). SSBCI programs are designed to expand access to capital, promote
economic resiliency, and create new jobs and economic opportunity.
Filling out this form and providing demographic information is optional; applicants are not
required to provide the requested information but are encouraged to do so. The entity collecting
this information cannot discriminate on the basis of whether an applicant provides this
information, or based on any information provided on this form. If you decline to provide this
information, it will not adversely affect your application.
The demographics-related information collected can only be used for purposes of the SSBCI
program and must not be used for any other purposes (e.g., marketing, sale to third parties). The
information collected must also not be used in a manner that violates any applicable
anti-discrimination laws, including, but not limited to, the following authorities: Title VI of the
Civil Rights Act of 1964 (Title VI), 42 U.S.C. § 2000d-1 et seq., and Treasury’s implementing
regulations, 31 C.F.R. part 22; Section 504 of the Rehabilitation Act of 1973 (Section 504), 29
U.S.C. § 794; Title IX of the Education Amendments of 1972 (Title IX), 20 U.S.C. § 1681 et
seq., and Treasury’s implementing regulations, 31 C.F.R. part 28; the Age Discrimination Act of
1975, 42 U.S.C. § 6101 et seq., and Treasury’s implementing regulations at 31 C.F.R. part 23.
If you believe you were discriminated against in connection with the provision of the information
provided on this form, contact: Director, Office of Civil Rights and Diversity, U.S. Department
of the Treasury, 1500 Pennsylvania Ave, N.W., Washington, DC 20220, or by email at
crcomplaints@treasury.gov.
PAPERWORK REDUCTION ACT NOTICE - OMB Control Number 1505-0227
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a valid control number assigned by OMB.

Applicants are encouraged to answer all of the questions below.
This information is being collected to help ensure that communities’ small business credit needs
are being fulfilled and allow SSBCI to analyze the populations that SSBCI funding is benefiting.
1. Minority-owned or controlled business status
For purposes of this form, minority individual means a natural person who identifies as
American Indian or Alaska Native; Asian American; Black or African American; Native
Hawaiian or Other Pacific Islander; Hispanic or Latino/a; or one or more than one of these
groups.
For purposes of this form, an applicant is a minority-owned or controlled business if the
business meets one or more of the following:
(1) if privately owned, 51 percent or more is owned by minority individuals;
(2) if publicly owned, 51 percent or more of the stock is owned by minority individuals;
(3) in the case of a mutual institution, a majority of the board of directors, account holders, and
the community which the institution services is predominantly comprised of minority
individuals; or
(4) one or more minority individuals have the power to exercise a controlling influence over the
business.
Is the applicant a minority-owned or
☐ Yes ☐ No ☐ Prefer not to respond
controlled business?
2. Women-owned or controlled business status
For purposes of this form, an applicant is a women-owned or controlled business if the business
meets one or more of the following:
(1) if privately owned, 51 percent or more is owned by females;
(2) if publicly owned, 51 percent or more of the stock is owned by females;
(3) in the case of a mutual institution, a majority of the board of directors, account holders, and
the community which the institution services is predominantly comprised of females; or
(4) one or more individuals who are females have the power to exercise a controlling influence
over the business.
Is the applicant a women-owned or controlled ☐ Yes ☐ No ☐ Prefer not to
business?
respond
3. Veteran-owned or controlled business status
For purposes of this form, an applicant is a veteran-owned or controlled business if the business
meets one or more of the following:
(1) if privately owned, 51 percent or more is owned by veterans;
(2) if publicly owned, 51 percent or more of the stock is owned by veterans;
(3) in the case of a mutual institution, a majority of the board of directors, account holders, and
the community which the institution services is predominantly comprised of veterans; or
(4) one or more individuals who are veterans have the power to exercise a controlling influence
over the business.
Is the applicant a veteran-owned or controlled ☐ Yes ☐ No ☐ Prefer not to
business?
respond

Each principal owner of the applicant is encouraged to answer the questions below.
This information is being collected to help ensure that communities’ small business credit needs
are being fulfilled and allow SSBCI to analyze the populations that SSBCI funding is benefiting.
For purposes of this form, a principal owner of the applicant is a natural person who, directly or
indirectly, through any contract, arrangement, understanding, relationship or otherwise, owns 25
percent or more of the equity of the business. If a trust owns, directly or indirectly, through any
contract, arrangement, understanding, relationship or otherwise, 25 percent or more of the equity
interests of the business, the trustee is a principal owner.
For each principal owner of the applicant, indicate which of the following categories the
principal owner identifies with. Submit a separate copy of this table for each principal owner of
the applicant (up to four).
1. Ethnicity
☐ Hispanic or Latino/a
☐ Not Hispanic or Latino/a
☐ Prefer not to respond
2. Race (select all that apply)
☐ American Indian or Alaska Native
☐ Black or African American
☐ Asian
☐ Native Hawaiian or Other Pacific Islander
☐ Indian
☐ Guamanian or Chamorro
☐ Chinese
☐ Native Hawaiian
☐ Filipino
☐ Samoan
☐ Japanese
☐ Pacific Islander (Other)
☐ Korean
☐ White
☐ Vietnamese
☐ Prefer not to respond
☐ Asian (Other)
3. Middle Eastern or North African Ancestry
☐ Middle Eastern or North African
☐ Not Middle Eastern or North African
☐ Prefer not to respond
4. Gender
5. Sexual Orientation
☐ Female
☐ Gay or lesbian
☐ Male
☐ Bisexual
☐ Nonbinary
☐ Straight, that is, not gay, lesbian, or bisexual
☐ Prefer to self-describe:
☐ Something else
_______________________________
☐ Prefer not to respond
☐ Prefer not to respond
6. Veteran Status
☐ Veteran
☐ Non-veteran
☐ Prefer not to respond