SSBCI-Technical-Assistance-Reporting-Guidance 2023-06-07

SSBCI TA Grant Program Reporting Guidance
DRAFT as of June 7, 2023

U.S. Department of the Treasury
State Small Business Credit Initiative
Technical Assistance Grant Program Reporting Guidance
DRAFT AS OF JUNE 7, 2023
Table of Contents
Section I. Overview ....................................................................................................................... 2
Section II. Definitions ................................................................................................................... 3
Section III. Reporting Deadlines ................................................................................................. 5
a.

Semiannual and Annual Reports During the Period of Performance........................................ 5
1.

Semiannual Federal Financial Report .......................................................................................... 5

2.

Annual TA Project Progress and Outcomes Report ..................................................................... 6

b.

Final Report at the Expiration of the Period of Performance .................................................... 6

c.

Summary of Reporting Deadlines ................................................................................................. 7

Section IV. Interim Reporting on Significant Developments; Notification of Fraud, Waste,
or Abuse ......................................................................................................................................... 7
Section V. Annual and Final Reports .......................................................................................... 8
a.

Annual TA Project Progress and Outcomes Reports .................................................................. 8

b.

Final TA Project Progress and Outcomes Report ..................................................................... 26

Section VI. Reporting Subawards and Executive Compensation, Maintenance of and
Access to Records, and Increase of Frequency and Scope of Reporting ............................... 27
Appendix 1 ................................................................................................................................... 29
Appendix 2 ................................................................................................................................... 31
Appendix 3 ................................................................................................................................... 34
Appendix 4 ................................................................................................................................... 35

Paperwork Reduction Act
The information collections discussed in this guidance will be submitted to the Office of
Management and Budget (OMB) under OMB control number 1505-0227 in accordance with the
Paperwork Reduction Act of 1995 (44 U.S.C. chapter 35). OMB approval for the information
collections included in this guidance is forthcoming and the information must be collected following
OMB approval. This document will be updated to reflect that approval.

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Section I. Overview
The American Rescue Plan Act of 2021 (ARPA) reauthorized and amended the Small Business
Jobs Act of 2010 to provide $10 billion to fund the State Small Business Credit Initiative
(SSBCI). SSBCI is a federal program administered by the U.S. Department of the Treasury
(Treasury) that is intended to expand access to capital, promote economic resiliency, create new
jobs, and increase economic opportunity. ARPA includes $500 million for technical assistance
(TA) funding. Treasury intends to award $200 million in federal grants to eligible recipients for
the provision of legal, accounting, and financial advisory services (TA services) to eligible small
businesses (TA Grant Program). The SSBCI Technical Assistance Grant Program Guidelines
were published on April 28, 2022. 1
TA Grants will be used to fund eligible TA providers’ provision of TA services to eligible
beneficiaries. Eligible beneficiaries are very small businesses (VSBs) and businesses owned and
controlled by socially and economically disadvantaged individuals (SEDI-owned businesses)
that are applying for, preparing to apply for, or have previously applied for an SSBCI capital
program or other federal or other jurisdiction small business program.
This guidance details the reporting and document-retention requirements for jurisdictions that
received a TA Grant (TA Grant recipients). Treasury will provide an online reporting portal that
TA Grant Program recipients must use to submit reports regarding their TA Grants. 2 Treasury
will provide more information about the submission format for reports in the coming months.
This guidance may be updated periodically.
Section II sets forth definitions of terms used in this guidance. Section III specifies the deadlines
for TA Grant recipients to submit reports. Section IV describes requirements relating to interim
reporting. Section V provides details regarding the information TA Grant Recipients must report
to Treasury in the required reports, which will support award implementation and compliance, as
well as assessment of outcomes. Section VI specifies additional requirements for TA Grant
recipients related to subaward and execution compensation reporting, maintenance of and access
to records and the frequency of reporting.
Treasury may release public reports or data based on the information reported by TA Grant
recipients. 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 other
sensitive information such as sensitive commercial or financial information associated with an
individual person or business.
Each TA Grant recipient is responsible for the implementation of its TA Grant approved by
Treasury, in accordance with the terms and conditions of its SSBCI TA Grant Agreement,
including applicable legal, regulatory, and program requirements. Each TA Grant recipient must
The SSBCI Technical Assistance Grant Program Guidelines in effect as of the date of this guidance are available at
https://home.treasury.gov/system/files/136/SSBCI-Technical-Assistance-Guidelines-April-2022.pdf.
2
To the extent that Treasury distributes templates or other materials to help carry out this TA Grant Reporting
Guidance, TA Grant recipients should follow the instructions included in those reporting materials.
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submit a certification using the form in Appendix 3 with every required report. In the case of a
non-Tribal entity or Tribal-affiliated entity (referred to as “Agent for the Tribes”) that directly
applies for and administers a TA Grant on behalf of a group of Tribal governments, the Agent for
the Tribes (in its individual capacity) must, in addition to the Appendix 3 certification, submit a
certification using the form in Appendix 4 prior to application approval and upon submission of
each required TA Grant Program report or request for additional disbursements of funding.
Section II. Definitions
The following definitions apply in this guidance.
Classroom-style TA. TA services that are provided through a stand-alone event that is targeted
towards eligible beneficiaries and has more than 10 attendees.
Eligible beneficiary. Any VSB or SEDI-owned businesses that is applying for, preparing to
apply for, or has previously applied for an SSBCI capital program or other federal or jurisdiction
small business program.
Eligible recipient. States, the District of Columbia, territories and Tribal governments that
submitted a timely and complete SSBCI capital program application.
Legal, accounting, or financial advisory firm. A nonprofit or for-profit entity that meets at least
one of the following criteria:
a. A primary purpose of the entity or a central part of the entity’s mission is to provide
legal, accounting, and/or financial advisory services,
b. The entity regularly markets or publicizes itself as providing legal, accounting, and/or
financial advisory services, or
c. At least 25% of the entity’s revenues or staff are dedicated to providing legal, accounting,
and/or financial advisory services.
Legal, accounting, and/or financial advisory services. The services listed in Section IV of the
SSBCI TA Grant Program Guidelines and other services that are similar to the those listed.
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.
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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.
SEDI-owned business.
• a business enterprise 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 (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 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 (see Executive Order 13985, under which “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
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.);
• a business enterprise that certifies that it is owned and controlled by individuals whose
residences are in Community Development Financial Institution (CDFI) Investment
Areas, as defined in 12 C.F.R. § 1805.201(b)(3)(ii); 3
• a business enterprise that certifies that it will build, open, or operate a location in a
CDFI Investment Area, as defined in 12 C.F.R. § 1805.201(b)(3)(ii); or
• a business enterprise that certifies that it is located in a CDFI Investment Area, as defined
in 12 C.F.R. § 1805.201(b)(3)(ii).
For purposes of the definition of “SEDI-owned business,” 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

The CDFI Fund evaluates Puerto Rico, but not other territories, in identifying CDFI Investment Areas. For
purposes of the SSBCI, Treasury has also evaluated American Samoa, Guam, the Northern Mariana Islands, and the
U.S. Virgin Islands and has determined that these territories in their entirety constitute CDFI Investment Areas,
because each of these territories has a poverty rate of at least 20 percent. See 12 C.F.R. § 1805.201(b)(3)(ii)(D)(1).

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(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.
Very small business (VSB). A business with fewer than 10 employees and includes independent
contractors and sole proprietors.
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 III. Reporting Deadlines
a. Semiannual and Annual Reports During the Period of Performance
1. Semiannual Federal Financial Report
During the period of performance set forth in the SSBCI TA Grant Agreement that each
TA Grant recipient executed in connection with their TA Grant, the TA Grant recipient must
submit a Form SF-425 (Federal Financial Report) to Treasury with cumulative information on a
semiannual basis with the first report period starting on the Federal Award Date and ending on
the sooner of the following March 31 or September 30. 4 Thereafter, the semiannual reports must
cover six month periods ending on March 31 and September 30 of each year until the period of
performance ends on the TA Grant in accordance with 2 C.F.R. § 200.328. 5 The Form SF-425 is

For TA Grants awarded fewer than 30 calendar days prior to the end of the semiannual reporting period (March 31
or September 30, as appropriate), the recipient will not be required to submit a semiannual report for that period.
However, information for that first semiannual reporting period should be included in the next period’s semiannual
report.
5
In accordance with 2 C.F.R. 200.328, when a TA Grant Program recipient has submitted a Form SF-425 for
purposes of facilitating a disbursement under a TA Grant within three months prior to an applicable semiannual
report submission deadline, Treasury will consider that Form SF-425 to satisfy the semiannual reporting submission
and no further reports for that period need be submitted. For example, if a TA Grant recipient submits a
Form SF-425 in support of a disbursement request on March 1, 2024, Treasury will consider the Form SF-425 to
satisfy the recipient’s required report submission for the semiannual period ending March 31, 2024.
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due at the end of the calendar month following the end of the reporting period (April 30 and
October 31). 6
In addition, for TA Grants that are $250,000 or less, the TA Grant Program recipient must
provide Treasury at the time of submission of the Form SF-425 with cumulative information for
the entire period of performance to date as of March 31 and September 30 of each year on
amounts expended to administer and oversee the award (administrative costs). As applicable to a
given award, such amounts may include direct administrative costs such as personnel, fringe, and
contractual costs, or indirect costs. 7 To satisfy this requirement, these recipients are only required
to report a single dollar amount of cumulative administrative costs.
Form SF-425 is available on Grants.gov along with instructions for completing the form at:
https://www.grants.gov/forms/post-award-reporting-forms.html. Table 1 below summarizes all
reporting deadlines.
2. Annual TA Project Progress and Outcomes Report
During the period of performance as set forth in the SSBCI TA Grant Agreement, each TA Grant
recipient must submit an Annual TA Project Progress and Outcomes Report for the 12-month
period ending March 31 (or any portion thereof, as applicable) of each year until the period of
performance ends on the TA Grant in accordance with 2 C.F.R. § 200.329. The first Annual TA
Project Progress and Outcomes Report period will start on the Federal Award Date and end on
March 31. 8 The Annual TA Project Progress and Outcomes Report is due at the end of the
calendar month following the end of the reporting period (April 30). 9 Table 1 below summarizes
all reporting deadlines. The data elements in the Annual TA Project Progress and Outcomes
report are set out in Section IV below.
b. Final Report at the Expiration of the Period of Performance
In accordance with 2 C.F.R. § 200.344(a), each TA Grant Program recipient must submit a
Final TA Project Progress and Outcomes Report and a final Form SF-425 no later than
120 calendar days after the end date of the period of performance as set forth in the SSBCI
TA Grant Agreement.
In accordance with 2 C.F.R. § 200.344(a), any subrecipient must submit to the TA Grant
recipient, no later than 90 calendar days after the period of performance end date (or an earlier
date as agreed upon by the recipient and subrecipient), all financial, performance, and other
reports, as required by the terms and conditions of the subaward agreement (see Section III.C of
6 If this deadline falls on a federal holiday or a weekend, the deadline will be the following business day.
7
For TA Grants that are $250,000 or less, fixed amount award procedures apply and therefore recipients are not
required to submit a budget or narrative justification. To help monitor the use of TA Grant funds, obtaining
information on the amount of funding used to administer and oversee awards is critical.
8
For TA Grants awarded fewer than 30 calendar days prior to the end of the annual reporting period (March 31), the
recipient will not be required to submit an annual report for that period. However, information for that first annual
reporting period should be included in the next period’s annual report.
9 If this deadline falls on a federal holiday or a weekend, the deadline will be the following business day.

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the SSBCI TA Grant Program Guidelines for more information on requirements for subaward
agreements).
c. Summary of Reporting Deadlines
Table 1. Summary of TA Grant Program Reporting Deadlines
Phase

Reports

Submission Deadlines

Form SF-425
During the Period
of Performance

For TA Grants $250,000 or
less, cumulative information
on administrative costs.
Annual TA Project Progress
and Outcomes Report

At the Expiration
of the Period of
Performance but
Before Award
Closeout

Semiannually on April 30 (cumulative
information through March 31) and
October 31 (cumulative information through
September 30).
Annually, for the period ending March 31
(due April 30).
One time report, due no later than
120 calendar days after the end date of the
award period of performance.

Final TA Project Progress
and Outcomes Report and
final Form SF-425

A subrecipient must submit required final
reports to the TA Grant recipient not later
than 90 calendar days after the end date of
the award period of performance (or an
earlier date agreed upon by the recipient and
subrecipient) (See Section II.b above).

Section IV. Interim Reporting on Significant Developments; Notification of Fraud, Waste,
or Abuse
In accordance with 2 C.F.R. § 200.329(e), events may occur between the scheduled performance
reporting dates that have significant impact upon a TA Grant or activities conducted under the
award. In such cases, the recipient must inform Treasury as soon as the following types of
conditions become known:
a. Problems, delays, or adverse conditions which will materially impair the ability to
meet the objective of the award. This disclosure must include a statement of the
action taken, or contemplated, and any assistance needed to resolve the situation.
b. Favorable developments, which enable meeting time schedules and objectives sooner
or at less cost than anticipated or producing more or different beneficial results than
originally planned.

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In addition, the recipient must immediately notify Treasury and the Treasury Inspector General
of any indication of fraud, waste, abuse, or potentially criminal activity pertaining to the TA
Grant Program funds.
Section V. Annual and Final Reports
Treasury intends to provide TA Grant recipients forms to assist with reporting all data elements.
The semiannual, annual, and final reports submitted by TA Grant recipients for their TA Grant
(or data contained therein) may be posted on Treasury’s website, used for policy reviews, or may
be otherwise shared. 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
other sensitive information such as sensitive commercial or financial information associated with
an individual person or business.
As explained above in Section III.a.1, each TA Grant recipient must submit Form SF-425
(Federal Financial Report) to Treasury semiannually as well as a final Form SF-425 no later than
120 calendar days after the end date of the period of performance. The following are details
regarding the annual and final reports that TA Grant recipients must also submit to Treasury.
a. Annual TA Project Progress and Outcomes Reports
TA Grant recipients must provide multiple categories of information in their Annual TA Project
Progress and Outcomes Reports during the award period of performance for the 12-month period
covered by the report. The tables below specify all data elements required, as well as the
frequency required for each category of information. In addition, TA Grant recipients must
submit a brief narrative update on the TA recipient’s TA plan that describes how the recipient’s
TA Grant implementation is progressing, including updates on the structure and offerings of
TA services if it has changed from the original TA plan submission. 10 Table 2 indicates the
frequency of reporting for each category.
Table 2. Annual Report Information and Frequency
Category of Information
TA Provider Data (see
Table 3 below)

Reporting Frequency
Data only must be reported one time for each TA provider. If
there are updates to previously reported information, including
“TA Services Provided” and “Amount of TA Grant Program
Funds Budgeted,” the recipient may submit updates to those
data elements, along with a statement that all other data
elements remain unchanged.
Eligible Beneficiary Data (if Data must be reported once for each business that receives
applicable) (see Table 4
TA services (except for attendees as a classroom-style TA
below)
services event). If a business receives more than one
TA service, please report each service separately. For example,
Note that certain changes to a recipient’s TA Grant require an amendment to the SSBCI TA Grant Agreement.
Treasury intends to publish procedures that specify when an amendment is required.

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if a business receives legal services in one month and then
accounting services in the following month, the legal services
should be reported as “TA Service 1” and the accounting
services as “TA Service 2.” If a business receives a TA service
that spans annual reporting periods, the continuing TA services
may be reported in a subsequent annual reporting period, but
should specify that the service is a continuing one in the “Brief
Description” field for the relevant TA service.
Classroom-Style TA
Services (if applicable) (see
Table 5 below)

Data must be reported once for each classroom-style TA event.

In addition, TA Grant recipients must provide a Privacy Notice and Privacy Act Statement (see
Appendix 1) to those from whom they collect data, or cause the persons or entities that collect
this data directly to provide the Privacy Notice and Privacy Act Statement.
The demographics-related data elements may only be collected and used for purposes of the
TA Grant Program and must not be used for any other purposes (e.g., marketing, sale to
third-parties). 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
Schedule 1, Section 2. c of the SSBCI TA Grant Agreement “Compliance with Applicable Law
and Regulations.” TA Grant Program recipients must establish processes to inform those from
whom they collect data of this limited usage when these data elements are collected. Each
recipient shall establish data privacy and security requirements for the demographic-related
information described in Table 4 that include appropriate measures to ensure that the privacy of
the individuals is protected. 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 is included
as Appendix 2 below. This sample form will be a useful tool for recipients.

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Table 3: TA Provider Data
Data Element
TA Provider
Relationship to TA Grant

TA Provider Type

Other TA Provider Type

Description
Enter the name of the TA provider.
Indicate which category applies to the TA provider:
-TA Grant recipient
-TA Grant subrecipient – entity of TA Grant recipient
(including political subdivisions)
-TA Grant subrecipient – legal, accounting, or financial
advisory firm
-TA Grant contractor – legal, accounting, or financial
advisory firm
Indicate what type of entity the TA provider is (if multiple
types apply, choose the one that best describes the TA
provider):
-State entity (including political subdivisions)
-Institution of higher education-affiliated entity, including
community colleges
-For-profit entity
-Non-profit entity
-Other
Text field for a description if selected “Other” for the data
element “TA Provider Type.”

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Data Element
Self-Certified SEDI-Owned
Business TA Provider

Description
Indicate whether the TA provider self-certified that it is a
SEDI-owned business. Select all categories in groups (1)
through (4) that apply, including all subcategories in group
(1) that apply:
-(1) TA provider self-certified it is owned and controlled by
individuals who have had their access to credit on reasonable
terms diminished as compared to others in comparable
economic circumstances, due to their:
-membership of a group that has been subjected to racial
or ethnic prejudice or cultural bias within American
society
-gender
-veteran status
-limited English proficiency
-disability
-long-term residence in an environment isolated from the
mainstream of American society
-membership of a Federally or state-recognized Indian
Tribe
-long-term residence in a rural community
-residence in a U.S. territory
-residence in a community undergoing economic
transitions (including communities impacted by the shift
towards a net-zero economy or deindustrialization)
-membership of an “underserved community” as defined
in Executive Order 13985 (see the definition of
“SEDI-owned business” in Section II above)
-(2) TA provider self-certified it is owned and controlled by
individuals whose residences are in CDFI Investment Areas,
as defined in 12 C.F.R. § 1805.201(b)(3)(ii)
-(3) TA provider self-certified that it will build, open, or
operate a location in a CDFI Investment Area, as defined in
12 C.F.R. § 1805.201(b)(3)(ii)
-(4) TA provider self-certified that it is located in a
CDFI Investment Area, as defined in 12 C.F.R.
§ 1805.201(b)(3)(ii)
-The TA provider did not certify

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Data Element
TA Services Provided

Description of Other TA
Services
Amount of TA Grant Funds
Budgeted

Description
Indicate the types of TA services the TA provider provides (if
multiple types apply, select all that apply):
-Legal services: Assisting with business formation or
adopting corporate governance documents
-Legal services: Obtaining needed registrations, licenses,
filings, and certifications
-Legal services: Advising on, or preparing documents for, the
business to enter into contracts
-Legal services: Legal services related to the business
obtaining capital from investors, such as the development of
financial instruments, investment term sheets, purchase
agreements, and shareholder rights agreements
-Legal services: Legal services related to a transfer of
ownership interests in a business, including employee stock
ownership plans
-Legal services: Other
-Accounting services: Preparing audits, financial statements,
or business records
-Accounting services: Digitizing financial records
-Accounting services: Advisory services or training regarding
accounting practices, recordkeeping, or accounting software
-Accounting services: Other
-Financial advisory services: Assisting with the establishment
of banking relationships or other financial services
-Financial advisory services: Assisting with applications for
government small business programs, including preparing
financial analyses
-Financial advisory services: Identifying sources of credit,
capital, grants, and other financing
-Financial advisory services: Advising on factors that may
impede access to business financing
-Financial advisory services: Advising on financial
management
-Financial advisory services: Developing presentations to
potential investors, financial models, and business plan
-Financial advisory services: Other
Text field for a description if selected “Legal Services:
Other,” “Accounting services: Other,” or “Financial advisory
services: Other” for the data element “TA Services Provided.”
Amount of TA Grant funds budgeted for the TA provider.

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Table 4. Eligible Beneficiary Data (if applicable)
Data Element
TA Provider
Eligible Beneficiary Identifier

Eligible Beneficiary Street
Address
Eligible Beneficiary City
Eligible Beneficiary State
Eligible Beneficiary Zip Code
NAICS Code

Full-Time Equivalent
Employees

Description
Enter the name of the TA provider.
Name of the business that is the eligible beneficiary. If the
eligible beneficiary prefers not to be identified by name, enter
an alphanumeric or numeric code that serves as an anonymous
identifier for the eligible beneficiary. Do not provide a Social
Security number as an identifier.
Enter the street address of the eligible beneficiary.
If the eligible beneficiary business does not provide an
address or prefers not to respond, enter “None provided.”
City of the eligible beneficiary.
State of the eligible beneficiary.
Zip code of the eligible beneficiary.
2017 North American Industry Classification System
(NAICS) code for the eligible beneficiary’s industry. Each
industry sector is defined by the U.S. Census Bureau; see
https://www.census.gov/programs-surveys/economiccensus/guidance/understanding-naics.html#par_textimage_1).
If multiple NAICS codes apply, choose the one that best
describes the eligible beneficiary.
The eligible beneficiary’s full-time equivalent employees
(FTEs), rounded to the nearest whole number, at the time
TA services are provided. This is determined by adding the
number of full-time employees and the 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.
Volunteers (i.e., individuals who receive no compensation,
including no in-kind compensation, for work performed) are
not considered employees.
This data element can be used to assess whether a business
qualifies as a VSB.

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Data Element
VSB

Self-Certified SEDI-Owned
Business Status

Description
Indicate whether the eligible beneficiary’s business is a VSB.
-Yes
-No
The TA Grant recipient may reasonably determine that a
business is a VSB based on the FTE number provided by the
business or a certification that the business meets the
definition of VSB.
Indicate whether the eligible beneficiary self-certified that it is
a SEDI-owned business. Select all categories in groups (1)
through (4) that apply:
-(1) Eligible beneficiary self-certified it is owned and
controlled by individuals who have had their access to credit
on reasonable terms diminished as compared to others in
comparable economic circumstances, due to their:
-membership of a group that has been subjected to racial or
ethnic prejudice or cultural bias within American society
-gender
-veteran status
-limited English proficiency
-disability
-long-term residence in an environment isolated from the
mainstream of American society
-membership of a Federally or state-recognized Indian Tribe
-long-term residence in a rural community
-residence in a U.S. territory
-residence in a community undergoing economic transitions
(including communities impacted by the shift towards a netzero economy or deindustrialization)
-membership of an “underserved community” as defined in
Executive Order 13985 (see the definition of “SEDI-owned
business” in Section II above)
-(2) Eligible beneficiary self-certified it is owned and
controlled by individuals whose residences are in CDFI
Investment Areas, as defined in 12 C.F.R. § 1805.201(b)(3)(ii)
-(3) Eligible beneficiary self-certified that it will build, open,
or operate a location in a CDFI Investment Area, as defined in
12 C.F.R. § 1805.201(b)(3)(ii)
-(4) Eligible beneficiary self-certified that it is located in a
CDFI Investment Area, as defined in 12 C.F.R. §
1805.201(b)(3)(ii)
-Eligible beneficiary did not certify

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Data Element
Description
Minority-Owned or Controlled Indicate whether the eligible beneficiary is a minority-owned
Business Status
or controlled business:
-Yes
-No
-Prefer not to respond
-The business did not answer
Women-Owned or Controlled Indicate whether the eligible beneficiary is a women-owned or
Business Status
controlled business:
-Yes
-No
-Prefer not to respond
-The business did not answer
Veteran-Owned or Controlled Indicate whether the eligible beneficiary is a veteran-owned or
Business Status
controlled business:
-Yes
-No
-Prefer not to respond
-The business did not answer
Race of Principal Owners
Indicate the race categories with which the principal owner or
principal owners identify (check all that apply): 11
-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
Treasury’s interim final rule on demographic data reporting contemplated that demographic data would be
collected and reported “for each principal owner of the business.” See State Small Business Credit Initiative;
Demographics-Related Reporting Requirements, 87 Fed. Reg. 13628, 13634 (Mar. 10, 2022), codified at 31 C.F.R.
Part 35. For purposes of this reporting guidance, Treasury will consider the requirement in that rule to be satisfied if
a recipient reports principal owner demographic data in the form set out in this table (i.e., where categories are
checked as they apply to one or more principal owners of a business, without principal owner demographics being
reported separately for each principal owner).

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Data Element
Ethnicity of Principal Owners

Middle Eastern or North
African Ancestry of Principal
Owners

Gender of Principal Owners

Gender of Principal Owners –
Self-Identification
Sexual Orientation of
Principal Owners

Veteran Status of Principal
Owners

TA Services Provided to the
Eligible Beneficiary

Description
Indicate the following ethnicity categories with which the
principal owner or principal owners identify (check all that
apply):
-Hispanic or Latino/a
-Not Hispanic or Latino/a
-Prefer not to respond
-The business did not answer
Indicate the following ancestry categories with which the
principal owner or principal owners identify (check all that
apply):
-Middle Eastern or North African
-Not Middle Eastern or North African
-Prefer not to respond
-The business did not answer
Indicate the following gender categories with which the
principal owner or principal owners identify (check all that
apply):
-Female
-Male
-Nonbinary
-Prefer to self-describe
-Prefer not to respond
-The business did not answer
Text field for description if selected “Prefer to self-describe”
in the data element “Gender of a Principal Owners.”
Indicate the following sexual orientation categories with
which the principal owner or principal owners identify (check
all that apply):
-Gay or lesbian
-Bisexual
-Straight, that is, not gay, lesbian, or bisexual
-Something else
-Prefer not to respond
-The business did not answer
Indicate the following categories with which the principal
owner or principal owners identify (check all that apply):
-Veteran
-Non-veteran
-Prefer not to respond
-The business did not answer
Provide the following information for TA services
provided to the eligible beneficiary. If more than one
discrete TA service is provided to an eligible beneficiary,
the TA provider can report additional TA services in the
fields for TA services 2 through 4.
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Data Element
Primary Purpose – TA Service
1

Primary Purpose of
TA Service 1 – Other
TA Service 1 – Brief
Description

Description
Indicate the primary purpose of TA service 1:
-Legal services: Assisting with business formation or adopting
corporate governance documents
-Legal services: Obtaining needed registrations, licenses,
filings, and certifications
-Legal services: Advising on, or preparing documents for, the
business to enter into contracts
-Legal services: Legal services related to the business
obtaining capital from investors, such as the development of
financial instruments, investment term sheets, purchase
agreements, and shareholder rights agreements
-Legal services: Legal services related to a transfer of
ownership interests in a business, including employee stock
ownership plans
-Legal services: Other
-Accounting services: Preparing audits, financial statements,
or business records
-Accounting services: Digitizing financial records
-Accounting services: Advisory services or training regarding
accounting practices, recordkeeping, or accounting software.
-Accounting services: Other
-Financial advisory services: Assisting with the establishment
of banking relationships or other financial services
-Financial advisory services: Assisting with applications for
government small business programs, including preparing
financial analyses
-Financial advisory services: Identifying sources of credit,
capital, grants, and other financing
-Financial advisory services: Advising on factors that may
impede access to business financing
-Financial advisory services: Advising on financial
management
-Financial advisory services: Developing presentations to
potential investors, financial models, and business plans
-Financial advisory services: Other
Text field for description if selected “Legal Services: Other,”
“Accounting services: Other,” or “Financial advisory services:
Other” for the data element “Primary Purpose – TA Service
1.”
Provide a brief, descriptive overview of TA service 1.

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Data Element
Style – TA Service 1

Description of Other Style –
TA Service 1
Hours – TA Service 1

Description
Indicate how the TA provider provided TA service 1.
-One-on-one (TA provider worked individually with eligible
beneficiary)
-Small-group (TA provider worked with a group to address
specific small business issues (generally 2-10 people, but
number may vary))
-Cohort (a group of eligible beneficiaries advanced through an
educational program or curriculum)
-Other
Text field for a description if selected “Other” for the data
element “Style – TA Service 1.”
Number of hours spent providing TA Service 1 to the eligible
beneficiary.

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Data Element
Primary Purpose –TA Service
2 (if applicable)

Primary Purpose of
TA Service 2 – Other
TA Service 2 – Brief
Description

Description
Indicate the primary purpose of TA service 2:
-Legal services: Assisting with business formation or adopting
corporate governance documents
-Legal services: Obtaining needed registrations, licenses,
filings, and certifications
-Legal services: Advising on, or preparing documents for, the
business to enter into contracts
-Legal services: Legal services related to the business
obtaining capital from investors, such as the development of
financial instruments, investment term sheets, purchase
agreements, and shareholder rights agreements
-Legal services: Legal services related to a transfer of
ownership interests in a business, including employee stock
ownership plans
-Legal services: Other
-Accounting services: Preparing audits, financial statements,
or business records
-Accounting services: Digitizing financial records
-Accounting services: Advisory services or training regarding
accounting practices, recordkeeping, or accounting software
-Accounting services: Other
-Financial advisory services: Assisting with the establishment
of banking relationships or other financial services
-Financial advisory services: Assisting with applications for
government small business programs, including preparing
financial analyses
-Financial advisory services: Identifying sources of credit,
capital, grants, and other financing
-Financial advisory services: Advising on factors that may
impede access to business financing
-Financial advisory services: Advising on financial
management
-Financial advisory services: Developing presentations to
potential investors, financial models, and business plans
-Financial advisory services: Other
Text field for description if selected “Legal Services: Other,”
“Accounting services: Other,” or “Financial advisory services:
Other” for the data element “Primary Purpose – TA Service
2.”
Provide a brief, descriptive overview of TA service 2.

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Data Element
Style – TA Service 2

Description of Other Style –
TA Service 2
Hours – TA Service 2

Description
Indicate how the TA provider provided TA service 2.
-One-on-one (TA provider worked individually with eligible
beneficiary)
-Small-group (TA provider worked with a group to address
specific small business issues (generally 2-10 people, but
number may vary))
-Cohort (a group of eligible beneficiaries advanced through an
educational program or curriculum)
-Other
Text field for a description if selected “Other” for the data
element “Style – TA Service 2.”
Number of hours spent providing TA Service 2 to the eligible
beneficiary.

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Data Element
Primary Purpose –TA Service
3 (if applicable)

Primary Purpose of
TA Service 3 – Other
TA Service 3 – Brief
Description

Description
Indicate the primary purpose of TA service 3:
-Legal services: Assisting with business formation or adopting
corporate governance documents
-Legal services: Obtaining needed registrations, licenses,
filings, and certifications
-Legal services: Advising on, or preparing documents for, the
business to enter into contracts
-Legal services: Legal services related to the business
obtaining capital from investors, such as the development of
financial instruments, investment term sheets, purchase
agreements, and shareholder rights agreements
-Legal services: Legal services related to a transfer of
ownership interests in a business, including employee stock
ownership plans
-Legal services: Other
-Accounting services: Preparing audits, financial statements,
or business records
-Accounting services: Digitizing financial records
-Accounting services: Advisory services or training regarding
accounting practices, recordkeeping, or accounting software
-Accounting services: Other
-Financial advisory services: Assisting with the establishment
of banking relationships or other financial services
-Financial advisory services: Assisting with applications for
government small business programs, including preparing
financial analyses
-Financial advisory services: Identifying sources of credit,
capital, grants, and other financing
-Financial advisory services: Advising on factors that may
impede access to business financing
-Financial advisory services: Advising on financial
management
-Financial advisory services: Developing presentations to
potential investors, financial models, and business plans
-Financial advisory services: Other
Text field for description if selected “Legal Services: Other,”
“Accounting services: Other,” or “Financial advisory services:
Other” for the data element
“Primary Purpose – TA Service 3.”
Provide a brief, descriptive overview of TA service 3.

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Data Element
Style – TA Service 3

Description of Other Style –
TA Service 3
Hours – TA Service 3

Description
Indicate how the TA provider provided TA service 3.
-One-on-one (TA provider worked individually with eligible
beneficiary)
-Small-group (TA provider worked with a group to address
specific small business issues (generally 2-10 people, but
number may vary))
-Cohort (a group of eligible beneficiaries advanced through an
educational program or curriculum)
-Other
Text field for a description if selected “Other” for the data
element “Style – TA Service 3.”
Number of hours spent providing TA Service 3 to the eligible
beneficiary.

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Data Element
Primary Purpose –TA Service
4 (if applicable)

Primary Purpose of
TA Service 4 – Other
TA Service 4 – Brief
Description

Description
Indicate the primary purpose of TA service 4:
-Legal services: Assisting with business formation or adopting
corporate governance documents
-Legal services: Obtaining needed registrations, licenses,
filings, and certifications
-Legal services: Advising on, or preparing documents for, the
business to enter into contracts
-Legal services: Legal services related to the business
obtaining capital from investors, such as the development of
financial instruments, investment term sheets, purchase
agreements, and shareholder rights agreements
-Legal services: Legal services related to a transfer of
ownership interests in a business, including employee stock
ownership plans
-Legal services: Other
-Accounting services: Preparing audits, financial statements,
or business records
-Accounting services: Digitizing financial records
-Accounting services: Advisory services or training regarding
accounting practices, recordkeeping, or accounting software
-Accounting services: Other
-Financial advisory services: Assisting with the establishment
of banking relationships or other financial services
-Financial advisory services: Assisting with applications for
government small business programs, including preparing
financial analyses
-Financial advisory services: Identifying sources of credit,
capital, grants, and other financing
-Financial advisory services: Advising on factors that may
impede access to business financing
-Financial advisory services: Advising on financial
management
-Financial advisory services: Developing presentations to
potential investors, financial models, and business plans
-Financial advisory services: Other
Text field for description if selected “Legal Services: Other,”
“Accounting services: Other,” or “Financial advisory services:
Other” for the data element “Primary Purpose – TA Service
4.”
Provide a brief, descriptive overview of TA service 4.

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Data Element
Style – TA Service 4

Description of Other Style –
TA Service 4
Hours – TA Service 4
Small Business Program
Referral

Name of Small Business
Program
Referral to Source of Capital

Description
Indicate how the TA provider provided TA service 4.
-One-on-one (TA provider worked individually with eligible
beneficiary)
-Small-group (TA provider worked with a group to address
specific small business issues (generally 2-10 people, but
number may vary))
-Cohort (a group of eligible beneficiaries advanced through an
educational program or curriculum)
-Other
Text field for a description if selected “Other” for the data
element “Style – TA Service 4.”
Number of hours spent providing TA Service 4 to the eligible
beneficiary.
If the TA provider made a referral to a small business program
with respect to the eligible beneficiary, check all that apply:
-SSBCI-supported lending program
-SSBCI-supported equity/venture capital program
-Other federal small business program
-Other small business program
-N/A
If the TA provider made a referral to a small business program
with respect to the eligible beneficiary, text field to specify the
name of each small business program to which the eligible
beneficiary was referred.
If the TA provider made a referral to a potential source of
capital with respect to the eligible beneficiary, check all that
apply:
-CDFI bank, thrift, 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
-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

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Data Element
Description
Description of Other Lender or Text field for a description of the type of lender or investor if
Other Investor
selected “Other lender” or “Other investor” for the data
element “Source of Capital Referral.” Note that the TA
provider is not required to specify the name of the lender or
investor.
Table 5: Classroom-Style TA Services (if applicable)
The TA Grant recipient must report the information below for each classroom-style TA service
event.
Data Element
Classroom-Style
TA Services
Classroom-Style TA
Service Event –
Primary Purpose

Description
Provide the following information for each Classroom-Style TA
Service Event
Indicate the primary purpose of the classroom-style TA service event:
-Legal services: Assisting with business formation or adopting
corporate governance documents
-Legal services: Obtaining needed registrations, licenses, filings, and
certifications
-Legal services: Advising on, or preparing documents for, the business
to enter into contracts
-Legal services: Legal services related to the business obtaining capital
from investors, such as the development of financial instruments,
investment term sheets, purchase agreements, and shareholder rights
agreements
-Legal services: Legal services related to a transfer of ownership
interests in a business, including employee stock ownership plans
-Legal services: Other
-Accounting services: Preparing audits, financial statements, or
business records
-Accounting services: Digitizing financial records
-Accounting services: Advisory services or training regarding
accounting practices, recordkeeping, or accounting software
-Accounting services: Other
-Financial advisory services: Assisting with the establishment of
banking relationships or other financial services
-Financial advisory services: Assisting with applications for
government small business programs, including preparing financial
analyses
-Financial advisory services: Identifying sources of credit, capital,
grants, and other financing
-Financial advisory services: Advising on factors that may impede
access to business financing
-Financial advisory services: Advising on financial management

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Primary Purpose of
Classroom-Style TA
Service Event –
Other
Classroom-Style TA
Service Event –
Brief Description
Classroom-Style TA
Service Event –
Attendees
Classroom-Style TA
Service Event - Date

-Financial advisory services: Developing presentations to potential
investors, financial models, and business plans
-Financial advisory services: Other
Text field for description if selected “Legal Services: Other,”
“Accounting services: Other,” or “Financial advisory services: Other”
for the data element “Classroom-Style TA Service Event – Primary
Purpose.”
Provide a brief, descriptive overview of the classroom-style TA service
event, including how the TA provider specifically targeted the event
towards eligible beneficiaries.
Text field for the number of attendees that attended classroom-style TA
service event.
Text field to provide the date of the classroom-style TA service event.

b. Final TA Project Progress and Outcomes Report
TA Grant recipients must provide the following in their Final TA Project Progress and Outcomes
Report, which is due to Treasury no later than 120 calendar days after the end date of the award
period of performance.
This report will consist of a narrative containing the following:
• An assessment of progress made toward achieving each of the recipient’s performance
goals established under the TA plan, including output measures and benchmarks
described in the recipient’s TA plan.
• A data-driven assessment of how the recipient’s TA Grant funds targeted the needs of
eligible beneficiaries.
• An evaluation of the recipient’s TA providers, including:
o An overview of the activities undertaken by TA providers, and
o The extent to which the TA providers achieved economic benefits to SEDI-owned
businesses and VSBs according to the economic benefit ratio (see Section V.b of the
SSBCI TA Program Guidelines “TA Provider Requirement: Connection to Economic
Benefits”).
• A description of how the recipient’s overall TA project supported or complemented
relevant small business programs.
• An assessment of the recipient’s strategy and efforts to reach eligible beneficiaries.
• A description of how the recipient identified gaps and opportunities in the recipient’s
ability to fulfill and achieve the goals of the TA plan and how the recipient addressed
those issues. This should include any updates on the structure and offerings of
TA services as the award progressed to meet the needs of eligible beneficiaries.
• Any other material information, which may include expected and actual benefits to
eligible beneficiaries of the TA Grant.
In addition, a final Form SF-425 must be submitted to Treasury no later than 120 calendar days
after the end date of the period of performance as set forth in the SSBCI TA Grant Agreement.
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Section VI. Reporting Subawards and Executive Compensation, Maintenance of and
Access to Records, and Increase of Frequency and Scope of Reporting
In accordance with Schedule 1, Section 2.b.iii of the SSBCI TA Grant Agreement on reporting
subawards and executive compensation, TA Grant recipients must report as part of their
registration profile at https://www.sam.gov by the end of the month following the month in
which this award is made, and annually thereafter, the names and total compensation for their
five most highly compensated executives for the preceding completed fiscal year, if: (1) the total
Federal funding authorized to date under this Federal award equals or exceeds $30,000 as
defined in 2 CFR 170.320; (2) in the preceding fiscal year, the TA Grant recipient received
(a) 80 percent or more of their annual gross revenues from Federal procurement contracts (and
subcontracts) and Federal financial assistance subject to the Transparency Act, as defined at
2 CFR 170.320 (and subawards), and (b) $25,000,000 or more in annual gross revenues from
Federal procurement contracts (and subcontracts) and Federal financial assistance subject to the
Transparency Act, as defined at 2 CFR 170.320 (and subawards); and (3) the information is not
otherwise public.
TA Grant recipients are required to report in http://www.fsrs.gov on subawards that equal or
exceed $30,000 in TA Grant funds no later than the end of the month following the month in
which the obligation was made. (For example, if the obligation was made on November 7, 2010,
the obligation must be reported by no later than December 31, 2010). For more information, see
the award term at 2 C.F.R. Part 170, Appendix A, which is incorporated into the SSBCI TA
Grant Agreement.
Schedule 1, Section 4 of the SSBCI TA Grant Agreement contains information regarding records
maintenance and access requirements that TA Grant recipients must comply with under their
TA Grants In particular, TA Grant recipients should maintain documentation evidencing their
determination that a TA provider that is a contractor or subrecipient, as applicable, is a legal,
accounting, or financial advisory firm. Treasury has published an FAQ specifying that for
purposes of the TA Grant Program, a legal accounting or financial advisory firm is an entity that
meets at least one of the following criteria:
(a) A primary purpose of the or a central part to entity’s mission is to provide legal,
accounting, and/or financial advisory services,
(b) The entity regularly markets or publicizes itself as providing legal, accounting, and/or
financial advisory services, or
(c) At least 25% of the entity’s revenues or staff are dedicated to providing legal,
accounting, and/or financial advisory services. 12
In making these determinations, TA Grant recipients may, but are not required to, require entities
to self-certify that they meet the definition set out in the appliable FAQ.
Treasury may unilaterally increase the frequency and scope of a TA Grant recipient’s reporting
requirements if Treasury finds the recipient to be high-risk. To determine whether a TA Grant
recipient is considered high-risk, Treasury will apply a risk evaluation approach that is consistent
SSBCI FAQs are published on Treasury’s website at State Small Business Credit Initiative (SSBCI) | U.S.
Department of the Treasury.
12

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with the principles set forth in 2 C.F.R. § 200.206. Treasury may find a TA Grant recipient to be
high-risk before or after Treasury executes the SSBCI TA Grant Agreement.
Because TA Grant recipients and TA providers will be receiving sensitive information, Treasury
strongly encourages TA Grant recipients and TA providers to establish robust protections against
data breaches and misuse of sensitive information and to comply with all applicable privacy laws
as set forth in Schedule 1, Section 9 of the SSBCI TA Grant Agreement. 2 C.F.R. § 200.303(e)
requires that TA Grant recipients and subrecipients take reasonable measures to safeguard
protected PII and other information that Treasury or the TA Grant recipient designates as
sensitive or the TA Grant recipient considers sensitive consistent with applicable federal, state,
local, and Tribal laws regarding privacy and responsibility over confidentiality.

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Appendix 1
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 will maintain a Privacy and Civil Liberties Impact Assessment that
describes what Treasury will do with the information your business provides in connection with
the SSBCI TA Grant program. 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 the terms and
conditions of the SSBCI TA Grant Agreement executed in the recipient in connection with its
TA Grant including federal laws with 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, to advance fairness and opportunity in underserved communities in the allocation of
federal resources, and to analyze the distribution of resources in federal programs, including to
assess program effectiveness and outcomes.
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, Compliance
Reviews, and Fairness in Federal Programs Files System of Records Notice (SORN), 88 Fed.
Reg. 12439; Treasury .015, General Information Technology Access Account Records, 85 Fed.
Reg. 73353; and Treasury .017, Correspondence and Contact Information, 81 Fed. Reg.
78266. 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 SORNs listed above, updates to
which may be periodically noted on Treasury’s website.
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Disclosure: Providing this information is voluntary. However, failure to furnish the requested
information may result in the denial of your request to receive SSBCI-supported technical
assistance. Providing demographic information is optional. If you decline to provide this
information, it will not adversely affect your eligibility to receive SSBCI-supported technical
assistance under Treasury’s SSBCI TA Grant Program rules and guidance.

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Appendix 2
SSBCI TA Grant Program Sample Form for Demographics-Related Data
This sample form may be used by a TA Grant recipient and/or its subrecipients and TA providers
to obtain demographics-related data. This sample form is provided for illustrative purposes as a
tool for recipients. A recipient may adopt its own form, provided that the form complies with all
SSBCI requirements.
Legal name of business: __________________________________________
The business has received technical assistance under the State Small Business Credit Initiative
Technical Assistance Grant Program (SSBCI TA Grant Program), which is a federal program
that provides grants to eligible recipients to carry out a technical assistance plan to provide legal,
accounting, and financial advisory services to small businesses that are applying, have previously
applied to, or plan to apply to an SSBCI Capital Program or other government program that
supports small businesses.
Filling out this form and providing the demographic information requested therein is optional;
the business not required to provide the requested information but is encouraged to do so. The
entity collecting this information cannot discriminate on the basis of whether an applicant
provides the information requested in this form, or based on any information provided on this
form. If you decline to provide the information requested in this form, it will not adversely affect
your ability to receive technical assistance.
The demographics-related information collected can only be used for purposes of the
SSBCI TA Grant 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 Equal Economic
Opportunity, 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 [_____________]
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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.
The business is encouraged to answer all of the questions below. This information is being
collected to help ensure that communities’ small business technical assistance and access to
credit needs are being fulfilled and allow SSBCI to analyze the populations that SSBCI TA
Grant Program 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 business a minority-owned or
Yes
No
Prefer not to
controlled business?
respond
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 business 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 business a veteran-owned or controlled Yes
No
Prefer not to
business?
respond
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SSBCI TA Grant Program Reporting Guidance
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The business is encouraged to answer the questions below for its principal owners.
This information is being collected to help ensure that communities’ small business technical
assistance and access to credit needs are being fulfilled and allow SSBCI to analyze the
populations that SSBCI TA Grant funding is benefiting.
For purposes of this form, a principal owner of the business 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.
If an applicant has more than one principal owner, the business is encouraged to check all of the
categories that apply for those principal owners. In this case, the business is not required to
submit a separate copy of this table for each principal owner. In addition, do not provide the
name of the principal owner or otherwise identify which principal owner corresponds to each
reported category.
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

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SSBCI TA Grant Program Reporting Guidance
DRAFT as of June 7, 2023

Appendix 3
Certification required with SSBCI TA Grant Reports
The undersigned, on behalf of the SSBCI TA recipient specified below, hereby makes the
following certifications:
1. By signing this report, I certify to the best of my knowledge and belief that the report is
true, complete, and accurate, and the expenditures, disbursements and cash receipts are
for the purposes and objectives set forth in the terms and conditions of the Federal award.
I am aware that any false, fictitious, or fraudulent information, or the omission of any
material fact, may subject me and the recipient to criminal, civil or administrative
penalties for fraud, false statements, false claims or otherwise. (U.S. Code Title 18,
Section 1001 and Title 31, Sections 3729–3730 and 3801–3812).
2. The information, certifications, attachments, and other information provided by the
recipient specified below to the U.S. Department of the Treasury related to its State
Small Business Credit Initiative (SSBCI) TA Grant are true and correct and do not
contain any materially false, fictitious, or fraudulent statement, nor any concealment or
omission of any material fact.
3. I make these certifications after reasonable inquiry of people, systems, and other
information available to the SSBCI TA recipient.
4. The SSBCI TA recipient is implementing the award in accordance with the terms and
conditions of its SSBCI TA grant agreement, including all applicable legal, regulatory,
and program requirements, including the SSBCI statute (12 U.S.C. § 5701 et seq.), the
U.S. Department of the Treasury’s SSBCI regulations, and SSBCI TA guidance to the
best of the undersigned’s knowledge; and
5. The undersigned has authority to execute and deliver this certification on behalf of the
SSBCI TA recipient.
IN WITNESS WHEREOF, this certificate has been duly executed on [ ] day of [ ], 202[ ].
[Name of Recipient]
By: _______________________________
Name of Authorized Official/Representative:
Title:

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SSBCI TA Grant Program Reporting Guidance
DRAFT as of June 7, 2023

Appendix 4
Certification Required of an Agent for the Tribes
In the case of a non-Tribal entity or Tribal-affiliated entity (referred to as “Agent for the Tribes)
that directly applies for and administers a TA Grant on behalf of a group of Tribal governments,
the Agent for the Tribes (in its individual capacity) must certify to Treasury prior to application
approval and upon submission of each required TA Grant Program report or request for
additional disbursements of funding that:
1. It is duly authorized to act as agent of each of the Tribal governments and of the group of
Tribal governments for the purposes of the SSBCI TA Grant Program.
2. It is capable of fulfilling program requirements on behalf of each of the Tribal
governments and the group of Tribal governments.
3. To the extent it is acting as an agent for the group of Tribal governments, it agrees to
comply with all terms and conditions of the TA Grant Agreement, including the SSBCI
statute, the TA Grant Program regulations, TA Grant Program guidance, and other
applicable Federal laws and regulations including with respect to the requirements for
reporting and use of funds.
4. To the extent that it is acting in its own capacity, it agrees to comply with all terms and
conditions of the TA Grant Agreement, including the SSBCI statute, the TA Grant
Program regulations, TA Grant Program guidance, and other applicable Federal laws and
regulations including with respect to the requirements for reporting and use of funds as if
it were a subrecipient.
5. To the extent that it is also implementing or will also implement an SSBCI capital
program or TA grant for another jurisdiction (e.g., for a U.S. state), it has disclosed that
relationship to the group of Tribal governments and has procedures in place to protect
against any conflicts of interest that may arise.
6. It is not debarred, suspended, or otherwise excluded from or ineligible for participation in
Federal assistance programs or activities prior to obtaining any grant funds from Treasury
per 31 CFR Part 19 and see also 2 CFR § 200.214.

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