Form 5C Disaster Home Loan Application

Disaster Home Loan Application

5C (03-06)

Disaster Home Loan Application

OMB: 3245-0018

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U.S. Small Business Administration

OMB Control No. 3245-0018

DISASTER HOME LOAN APPLICATION
--FOR SBA INTERNAL USE ONLY--

Date Received Stamp

Declaration Information Label

FILING REQUIREMENTS
We want to provide as much help as possible toward your recovery from the disaster. The information we ask you
for is necessary if we are to provide as much assistance as possible, as quickly as possible. FOR THIS REASON,
WE ASK YOU TO CONTACT AN SBA DISASTER REPRESENTATIVE AT ONCE IF YOU HAVE ANY
PROBLEMS PROVIDING THE INFORMATION LISTED BELOW. Disaster loans must comply with the laws
passed by Congress, and therefore we may not always be able to do all that you ask.
For your protection, if you use a contractor, we urge you to consider one that is bonded.
ALL LOANS
Î Complete and sign this application form (SBA Form 5C).
Î Complete and sign the Tax Information Authorization (IRS Form 8821) enclosed with this application. This income information,
obtained from the IRS, will help us determine your repayment ability. If we need additional income information, you may be asked
to provide copies of your income tax returns including all schedules.

Î If you have changed employment within the past 2 years, attach a copy of a current (within 1 month of the application date) pay
Î

stub.
If you have insurance and your claim has been settled, attach a copy of your settlement sheet or adjuster’s proof of loss. If your
claim has not been settled, attach a copy of the schedule of coverage from your insurance policy. This information is needed
because the law only allows us to loan the difference between your disaster losses and any insurance or other recoveries.

Î If you have any questions about this application, you may call us at 1-800-659-2955. If you decide to pay someone (an attorney,
accountant, friend, etc.) to help fill out this application, that person must read and sign Item 9 in Section F.

NOTE: IF YOUR APPLICATION IS APPROVED
THE FOLLOWING ITEMS MAY BE NEEDED
Î If you OWN your residence, a legible copy of the COMPLETE deed, including the legal description of the property.
Î If you RENT your residence, a copy of your complete rental or lease agreement, or letter from your landlord describing the terms of
your lease, or a copy of a utility bill that shows your place of residence at the time of the disaster. This enables us to establish your
eligibility for a disaster loan.

Î If you had damage to a mobile home, a copy of the title to the mobile home being claimed. If you own the lot where the mobile
home is located, a copy of the COMPLETE deed to the lot, including the legal description.

Î If you have damage to an automobile, a copy of the current registration to any damaged automobile or other vehicles you have
included in your losses.
SBA Form 5C (03-06) Ref SOP 50 30

A
1

INFORMATION ABOUT THE APPLICANT
Name and Information

First Name

Middle

Last Name

Social Security Number

Birth Date

Family Size

Marital Status
Married
Email Address (Optional)

Separated

Unmarried (Single, Divorced, Widowed)

SBA Employee
Self-Employed

Home

Work

Business

Relative

Damaged Address

IS THIS YOUR PRIMARY RESIDENCE?

YES

County

Other

State

Zip

NO
Rent

State

Zip

Phone Numbers

Home Number

Work Number

Alternate

Closest Relative Not Living With You

Name

Address

Phone Number

Employment

Employer
Address

Temporary

Own Home

City

SAME AS MAILING ADDRESS

Address

Vacation

County

City

YES

Mailing Address

Type:
Address

YES

City

Years

Months

State

Zip

Gross Income

NOTE: Do not include the income of your spouse here. If your spouse's income is to be considered, complete Section B.
Employment income, including self-employment income BEFORE
$
per
week
month
deductions of any kind for income taxes, social security, state and local
taxes, retirement, insurance, etc.
Supervisor's Name
Title
Occupation

year

Other Income

Examples of OTHER income are regular part-time work, social security, retirement, disability, stock dividends, interest income, commissions,
living allowance, transportation allowance, and similar items. Payments from alimony, child support and/or separate maintenance should also
be included as OTHER income if the income will be used to help repay this loan.
Sources of OTHER Income (describe)
Amount of Other Income
per
week
month
year
$

per
week
$
per
week
$
per
week
$
I own 20 % or more of a corporation, partnership, limited partnership, or LLC

SBA Form 5C (03-06) Ref SOP 50 30

YES

month

year

month

year

month

year
NO

INFORMATION ABOUT THE JOINT APPLICANT
Note: If Not Applicable, Proceed To Section "C"

Name and Information

First Name

Middle

Last Name

Social Security Number

Birth Date

Family Size

Marital Status
Married
Email Address (Optional)

Mailing Address
Home

Type:
Address

Separated

Unmarried (Single, Divorced, Widowed)

SBA Employee
Self-Employed

Work

Business

Relative

Temporary

Other

State

Work Number

Zip

Alternate

Closest Relative Not Living With You
Address

Phone Number

Employment

Employer
Address

Phone Numbers

Name

Vacation

County

Home Number

YES

Same as Applicant

City

YES

City

Years

Months

State

Zip

Gross Income

NOTE: Do not include any income shown in Section A.
Employment income, including self-employment income BEFORE
deductions of any kind for income taxes, social security, state and local
taxes, retirement, insurance, etc.
Title

per

week

month

year

Supervisor's Name

Occupation

Other Income

$
$
$
$
8

Amount of Other Income
per
week
month

year

per

week

month

year

per

week

month

year

per

week

month

year

I own 20 % or more of a corporation, partnership, limited partnership, or LLC

YES

C
1

FINANCIAL INFORMATION FOR APPLICANT AND JOINT APPLICANT
MONTHLY HOUSING COST

IF you RENT your residence, please complete the line below
Landlord (name/address/phone no.)

Monthly rent

Renter's insurance
month

per

year

OR
IF you OWN your residence, please complete the remainder of this section
Name and address of mortgage holder (if any)

Monthly payment

Balance owed

$
Name and address of second mortgage holder (if any)

Monthly payment

Balance owed

If NOT included in payment(s) above, OR if residence is paid for, please provide (as applicable):

Total real estate taxes
month

$
2

Hazard insurance
per

year

DEBTS AND CREDIT REFERENCES
Use the back page (G) if more space is needed.

Name of Creditor(s)

TOTALS
3

Type of Debt

Include any total from the last page.

EXTRAORDINARY EXPENSES
(REQUIRED AND CONTINUING)

Condo/association fee
month

per

year

$
$
$
$

year

List all types of debts, including loans, credit cards, charge accounts, delinquent
taxes, etc. Include loan payments, real estate taxes and insurance for any real
estate other than primary residence (in Item 1 above). List all debts even if
payments are not currently due.

Monthly Payment Balance Owed
$

Total Amount

How Secured
(If by real estate, give address)

Examples of Extraordinary Expenses are: unusually high and long-term medical
costs, child care, child support, alimony, tuition for schools, required by medical
disability, etc., that are expected to continue for 10 months or more.

NOTE: DO NOT include normal living expenses

Amount Per Month

month

per

Description of expense (please be specific)

STATEMENT OF ASSETS
If this application is for an individual, list only your assets.
If this is a JOINT application, include the assets of both the APPLICANT and JOINT APPLICANT.
Note:

If any of the assets listed in this section were damaged by the disaster, please value them at their REPAIRED value.

Cash and Bank Accounts

Include Certificates of Deposit but do not include IRA's, Keogh's, or similar
restricted retirement accounts. Do not include insurance proceeds.

Total Amount

$
Total Amount

IRA's, Keogh's and other similar restricted retirement accounts

$
Total Amount

Market value of stocks, bonds and other securities

$
Total Amount

Resale value of furnishings, household goods and appliances

Resale value of ALL real estate (land and buildings) including residence(s)

Note: Be sure all mortgage, tax, and insurance payments on these properties are listed in Items 1 or 2 of Section C.

Property and Location (address)

Year
Purchased

Purchase Price

Year Mortgage
Pays Off

Current Resale Value

Primary residence, address

Other property, type*, and address
Other property, type*, and address
Other property, type*, and address

* Such as vacation home, rental property, vacant land, etc.

Resale value of other assets (vehicle(s), boat, recreational vehicle, other assets)

Make and year

Total amount

$
Make and year

Total amount

$
Description

Total amount

$
Description

Total amount

$
Description

Total amount

DISASTER INFORMATION
Note: SBA disaster loans are available for the amount of the disaster-related damages, LESS any
insurance recoveries and assistance from other disaster relief agencies.

ESTIMATE OF THE COST TO REPAIR/REPLACE THE DISASTER-DAMAGED PROPERTY
If unknown at this time, just
place a question mark in the
space provided.

Real Estate

Personal Property, including auto(s)

INSURANCE INFORMATION
CHECK the correct block(s) below to show the status of your insurance.
NO INSURANCE coverage of any kind (flood or other) was in force for this loss.
(IF this block is checked, skip to Item 3 below.)

FLOOD INSURANCE for this loss:

Name and address of insurance agent or company

OTHER INSURANCE for this loss:
____Homeowners

Settled for

Pending

Other (explain)

Area code/telephone no.

Policy no.

Settled for

Pending

Other (explain)

____Auto
____Other (e.g., earthquake, windstorm)

Name and address of insurance agent or company

Area code/telephone no.

Policy no.

Name and address of insurance agent or company

Area code/telephone no.

Policy no.

Note: It is not necessary that you settle with your insurance company before you apply for an SBA disaster loan. If your claim is
questioned or otherwise delayed, we can loan the full amount of the damages so you can begin repairs. The insurance settlement is
then assigned to us to reduce the loan once the settlement is received.

INFORMATION ABOUT OTHER DISASTER ASSISTANCE
CHECK the correct box to show the status of aid from other disaster relief agencies.
NO AID was received or is expected from any Federal, state, local, or private relief agencies.
AID WAS received or is expected from Federal, state, local, or private agencies, as follows:
Name of agency

Amount received/expected

Name of agency

$
Amount received/expected
$

OTHER INFORMATION
Note: This information also applies to Joint Applicant, if any. If more space is needed, use back page (G).

I have never had an SBA loan or an SBA guaranteed loan,
Except:
I have never had any other Federal loans or Federally
guaranteed loans, except:
I am not delinquent on any Federal taxes, direct or guaranteed loans
(FHA, VA, student, etc.), contracts, grants, or any child support
payments, except:
I have never been bankrupt, except:

I have no judgments or lawsuits pending against me, except:

I have never been convicted of a felony committed in connection with a Provide complete details
riot or civil disorder, nor am I engaged in the production or distribution
of any product or service that has been determined to be obscene by a
court of competent jurisdiction. except:

ARE YOU A U.S. CITIZEN?

If my loan is approved, I may be eligible for additional funds to cover the cost of safeguarding my property from similar
damages as caused by this disaster. It is not necessary for me to submit the description and cost estimates with the
application. SBA approval of these safeguarding measures will be required before any loan increase. By checking this
box, I am interested in having SBA consider this increase.

I have not paid a representative (attorney, accountant, etc.) to assist me with this application, except:

1
2
3

YES

Name and address of representative (please print)

SBA office location

account (loan) number

Agency name, office location

account (loan) number

Agency name, office location

account (loan) number

Provide complete details such as dates, location and current status

Provide complete details such as dates, parties involved and current
status

If you are not a U.S. Citizen, please provide complete details in Section "G".

Fee charged or agreed upon
$

If anyone completed this application on my behalf, whether there is any charge or not, that person must sign in
this space below:
Date signed

Signature of representative

10
11
12
13
14

I authorize my insurance company, bank, financial institution, or other creditors to release to SBA all records and
information necessary to process this application.
SBA has my permission, as required by the Privacy Act, to release information to state, local or private disaster relief
services (Red Cross, Salvation Army, Mennonite Disaster Services, etc.).
If my loan is approved, additional information may be required prior to loan closing. I will be advised in writing what
documents will be needed to obtain my loan funds.
I have received and read a copy of the “STATEMENTS REQUIRED BY LAWS AND EXECUTIVE ORDERS” which
was attached to this application.
All the information on this application and any attachments is true to the best of my knowledge and you may rely on it to
provide disaster loan assistance. All damages claimed are a direct result of the declared disaster. I understand that I could
lose my benefits and could be prosecuted by the U.S. Attorney for making false statements.

Reference 18 U.S.C. 1001 and/or 15 U.S.C. 645.

SIGNATURES: Be sure to Sign and date the application in INK. If there is a JOINT
APPLICANT, the joint applicant must also Sign and date in INK in the space provided.
Signature of APPLICANT

Date signed

Signature of JOINT APPLICANT

Date signed

PLEASE CHECK THE “FILING REQUIREMENTS” INSTRUCTIONS ON THE FRONT OF THIS FORM TO SEE
THAT YOU HAVE INCLUDED THE NECESSARY SUPPORTING DOCUMENTS.
RETURN THE COMPLETED APPLICATION PACKAGE TO SBA PRIOR TO THE FILING DEADLINE SHOWN
ON THE FRONT OF THIS FORM.

ADDITIONAL INFORMATION
Please refer to Section and Item Number

NOTE: PLEASE READ, DETACH AND KEEP FOR YOUR RECORDS
STATEMENTS REQUIRED BY LAWS AND EXECUTIVE ORDERS
To comply with legislation passed by the Congress and Executive Orders issued by the President, Federal executive
agencies, including the Small Business Administration (SBA), must notify you of certain information. You can find the
regulations and policies implementing these laws and Executive Orders in Title 13, Code of Federal Regulations (CFR),
Chapter 1, or our Standard Operating Procedures (SOPs). In order to provide the required notices, the following is a brief
summary of the various laws and Executive Orders that affect SBA’s Disaster Loan Programs.
FREEDOM OF INFORMATION ACT (5 U.S.C. § 552)
This law provides, with some exceptions, that we must make records or portions of records contained in our files available to
persons requesting them. This generally includes aggregate statistical information on our disaster loan programs and other
information such as names of borrowers (and their officers, directors, stockholders or partners), loan amounts at maturity,
the collateral pledged, and the general purpose of loans. We do not routinely make available to third parties your proprietary
data without first doing pre-notification, as required by Executive Order #12600, or information that would cause
competitive harm or constitute a clearly unwarranted invasion of personal privacy.
Send a request under this Act to the SBA office maintaining the records requested and identify it as a Freedom of
Information Act (FOIA) request. The request must describe the specific records you want. For information about the FOIA,
contact the Chief, FOI/PA Office, 409 3rd Street, SW, Suite 5900, Washington, DC 20416, or by e-mail at [email protected].
PRIVACY ACT (5 U.S.C. § 552a)
You can request to see or get copies of any personal information that we have in your file, when that file is retrieved by
individual identifiers, such as name or social security numbers. Requests for information about another party may be denied
unless we have the written permission of the individual to release the information to the requestor or unless the information
is subject to disclosure under the Freedom of Information Act. This form contains written permission for us to disclose the
information resulting from this collection with state, local or private disaster relief services.
Under the provisions of the Privacy Act, you are not required to provide social security numbers. However, we use social
security numbers to distinguish between people with a similar or the same name. Failure to provide this number may not
affect any right, benefit or privilege to which you are entitled by law, but having the number makes it easier for us to more
accurately identify to whom adverse credit information applies and to keep accurate loan records.
The Privacy Act authorizes SBA to make certain “routine uses” of information protected by that Act. One such routine use
for SBA’s loan system of records is that when this information indicates a violation or potential violation of law, whether
civil, criminal, or administrative in nature, SBA may refer it to the appropriate agency, whether Federal, State, local or
foreign, charged with responsibility for or otherwise involved in investigation, prosecution, enforcement or prevention of
such violations. Another routine use of personal information is to assist in obtaining credit bureau reports, on the Disaster
Loan Applicants and guarantors for purposes of originating, servicing, and liquidating Disaster loans. See, 69 F.R. 58598,
58617 (and as amended from time to time) for additional background and other routine uses.
Note: Any person concerned with the collection, use and disclosure of information under the Privacy Act may contact the
Chief, FOI/PA Office, 409 3rd Street, SW, Suite 5900, Washington, DC 20416 or by e-mail at [email protected] for information
about the Agency’s procedures relating to the Privacy Act and the Freedom of Information Act.
RIGHT TO FINANCIAL PRIVACY ACT OF 1978 (12 U.S.C. § 3401 et seq.)
This notifies you, as required by the Right to Financial Privacy Act of 1978 (Act), of our right to access financial records
held by financial institutions that were or are doing business with you or your business. This includes financial institutions
participating in loans or loan guarantees.
The law provides that we may access your financial records when considering or administering Government loan or loan
guaranty assistance to you. We must give a financial institution a certificate of our compliance with the Act when we first
request access to your financial records. No other certification is required for later access. Our access rights continue for the
term of any approved loan or loan guaranty. We do not have to give you any additional notice of our access rights during the
term of the loan or loan guaranty.

We may transfer to another Government authority any financial records included in a loan application or about an approved
loan or loan guaranty as necessary to process, service, liquidate, or foreclose a loan or loan guaranty. We will not permit any
transfer of your financial records to another Government authority except as required or permitted by law.
CONSUMER CREDIT PROTECTION ACT (15 U.S.C. 1601 et seq.)
This legislation gives an applicant who is refused credit because of adverse information about the applicant's credit,
reputation, character or mode of living an opportunity to refute or challenge the accuracy of such reports. Therefore, if we
decline your loan in whole or in part because of adverse information in a credit report, you will be given the name and
address of the reporting agency so you can seek to have that agency correct its report, if inaccurate. If we decline your loan
in whole or in part because of adverse information received from a source other than a credit reporting agency, you will be
given information but not the source of the report.
Within 3 days after the consummation of the transaction, any recipient of an SBA loan which is secured in whole or in part
by a lien on the recipient’s residence or household contents may rescind such a loan in accordance with “Regulation Z” of
the Federal Reserve Board.
DEBT COLLECTION ACT OF 1982 AND DEFICIT REDUCTION ACT OF 1984 (31 U.S.C. § 3701 et
seq. and other titles)
These laws require us to aggressively collect any delinquent loan payments. You must give your taxpayer identification
number to us when you apply for a loan. If you receive a loan and do not make payments when they become due, we may
take one or more of the following actions (this list may not be exhaustive):
*Report the delinquency to credit reporting bureaus.
*Offset your income tax refunds or other amounts due you from the Federal Government.
*Refer the account to a private collection agency or other agency operating a debt collection center.
*Suspend or debar you from doing business with the Federal Government.
*Refer your loan to the Department of Justice.
*Foreclose on collateral or take other actions permitted in the loan instruments.
*Garnish wages.
*Sell the debt.
*Litigate or foreclose.
PLEASE NOTE: The estimated burden for completing this form is 1.5 hours. Your responses to the requested information
are required in order to obtain a benefit under our Disaster Home Loan Program. However, you are not required to respond
to any collection of information unless it displays a currently valid OMB approval number. If you have questions or
comments concerning any aspects of this information collection, please contact the U.S. Small Business Administration
Information Branch, 409 3rd Street, SW, Washington, DC 20416 and Desk Officer for SBA, Office of Management and
Budget, Office of Information and Regulatory Affairs, 725 17th Street, NW, Washington, DC 20503. (3245-0018) PLEASE
DO NOT SEND FORMS TO OMB.

File Type	application/pdf
File Title	5Cd.xls
Author	taprintu
File Modified	2006-09-20
File Created	2006-09-20