Form 5M Pre-Disaster Mitigation Small Business Loan Application

U.S. Small Business Administration PRE-DISASTER MITIGATION SMALL BUSINESS LOAN APPLICATION

OMB No. 3245-0326

Filing Deadline

Declaration Number

Pre-Disaster Mitigation Loans are available only in communities participating in the Federal Emergency Management Agency’s Pre-Disaster Mitigation Program. These loans may be used only for mitigation measures against the type of disaster identified as high risk by your participating Pre-Disaster Mitigation community.

FILING REQUIREMENTS (please submit)

1. Copies of the applicant’s 3 most recent Federal Income Tax Returns, including all schedules. If this is a new business that has not filed 3 Federal Tax Returns, submit the ones you have filed. Also, complete and sign the attached Tax Information Authorization (IRS Form 8821). Sole proprietors need only submit the IRS Form 8821. We will contact you if we need any additional information (i.e., forecasts, etc.). 2. A current (dated within 90 days of application) business balance sheet (you may use the attached Personal Financial Statement (SBA Form 413) if you are a sole proprietorship), a current profit and loss statement, and a current schedule of liabilities. We attached a sample schedule of liabilities (SBA Form 2202) for your convenience. 3. For each: 1) proprietor; or 2) limited partner who owns 20% or more interest and each general partner; or 3) each stockholder or entity owning 20% or more of voting stock, a current (dated within 90 days of application) personal financial statement (you may use SBA Form 413 for this purpose). Entities (except sole proprietorships) must also submit a complete copy, including all schedules, of the entity’s most recent Federal Income Tax Return. 4. A complete copy, including all schedules, of the latest Federal Income Tax Return for each affiliate. Affiliates include, but are not limited to, business parents, subsidiaries or other businesses with common ownership or management. An authorized individual must complete and sign the attached IRS Form 8821 for each affiliate. 5. A letter from your local or State coordinator indicating that the proposed mitigation measure (in general terms) will be undertaken in the participating community and is within the goals and priorities of the participating pre-disaster mitigation community. 6. A cost estimate (contractor’s bid) of the proposed mitigation measure and an outline of how the proposed mitigation measure will protect your real property or leasehold improvements from future disasters in your participating pre-disaster mitigation community.

IF SBA APPROVES YOUR LOAN, WE MAY REQUIRE ADDITIONAL INFORMATION BEFORE LOAN CLOSING. WE WILL ADVISE YOU, IN WRITING, OF WHAT DOCUMENTS WE WILL NEED.

7. APPLICANT’S LEGAL NAME

8. TELEPHONE NUMBER (including area code)

9. TRADE NAME (if different from legal name)

10. FEDERAL E.I.N. (if applicable)

11. MAILING ADDRESS

Number, street, and/or P.O. Box No.

City

County

State

Zip

12. MITIGATION PROJECT PROPERTY ADDRESS(ES) (If you need more space, attach additional sheets.)

Number, street, or rural route

City

County

State

Zip

13. MITIGATION PROJECT PROPERTY IS: Owned Leased

14. TYPE OF BUSINESS

15. AMOUNT OF LOAN REQUEST

16. UNDER CURRENT MGMT. SINCE:

17. DATE BUSINESS ESTABLISHED AT MITIGATION PROJECT PROPERTY LOCATION

18. NUMBER OF EMPLOYEES

19. MANAGEMENT (If you need more space, attach additional sheets.) Complete for each: 1) proprietor; or 2) limited partner who owns 20% or more interest and general partner, or 3) stockholder owning 20% or more voting stock.

Name

Title/Office

% Owned

Social Security Number*

(Area Code) Telephone Number

Date of Birth*

Place of Birth*

Name

Title/Office

% Owned

Social Security Number*

(Area Code) Telephone Number

Date of Birth*

Place of Birth*

*For information about these questions, see the attached Statements Required by Laws and Executive Orders.

SBA Form 5M (5-03)

20. For the applicant business and each individual listed in Item 19, please respond to the following questions, providing dates and details. (If you need more space, attach additional sheets.) a. Has never been involved in bankruptcy or insolvency proceedings, except as stated:________________________________. b. Has no outstanding judgments, tax liens, or pending lawsuits against them, except as stated:_________________________. c. Has not been convicted of a criminal offense committed during and in connection with a riot or civil disorder, nor is such person or the applicant 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 as stated:_____________________________________________________________. d. Has never had any Federal loans or Federally guaranteed loans, except as stated:__________________________________. e. Is not delinquent on any Federal taxes, direct or guaranteed loans (SBA, FHA, VA, student, etc.), contracts, grants, or child support payments, except as stated:______________________________________________________________________.
21. No owner, owner’s spouse or household member works for SBA, except:__________________________________________
YES NO 22. Are any of the individuals listed in Item 19: (a) presently under indictment, on parole or probation, or have they been; (b) charged with or arrested for any criminal offense (including offenses which have been dismissed, discharged, or not prosecuted) other than a minor motor vehicle violation; or (c) convicted, placed on pretrial diversion, or placed on any form of probation including adjudication withheld pending probation for any criminal offense other than a minor motor vehicle violation?
23. If you are a sole proprietor, are you a U.S. citizen? YES NO
24. ORGANIZATION Sole Proprietorship Partnership Limited Partnership Corporation Other­­­­­­­­­­­­­­­­­:______________________ TYPE
Name and address of representative (please print and sign) Fee charged or agreed upon If anyone completes this application for you, whether you pay a fee for this service or not, that person must sign in the space below: U nless the NO box is checked I give permission for SBA to discuss any portion of this application with the representative listed above. NO
AGREEMENTS AND CERTIFICATIONS
On behalf of the undersigned individually (each person listed in Item 19) and for the applicant business: I authorize my bank, financial institution, or other creditors to release to SBA all records and information necessary to process this application. You have my permission to release information in connection with this application to Federal, State, local, or private organizations that provide relief for disaster related purposes. I will not exclude from participating in, or deny the benefits of, or otherwise subject to discrimination under any program or activity for which applicant receives Federal financial assistance from SBA, any person on grounds of age, color, handicap, marital status, national origin, race, religion or sex. I will report to the SBA Office of the Inspector General, Washington, D.C. 20416, any Federal employee who offers, in return for compensation of any kind, to help get this loan approved. I have not paid anyone connected with the Federal government for help in getting this loan. All information in this application is true and complete to the best of my knowledge. All financial statements submitted with the application fully and accurately present the financial position of the business. I have not omitted any disclosures in these financial statements. This certification also applies to any financial statements submitted after this date. I understand that false statements may result in the forfeiture of benefits and possible prosecution by the U.S. Attorney General (reference 18 U.S.C. 1001 and/or 15 U.S.C. 645).
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