SBA Form 2276 Part Supplemental Information for Gulf Opportunity Pilot Loan

S

OMB Approval No.: 3245-0355

Effective Date: 11/07/2005

Expiration Date: 5/31/2006

MB Approval No.: 3245-0348

Effective Date: 02/19/2004

Expiration Date: 02/28/2007

upplemental Information for Gulf Opportunity Pilot Loan Program

Borrower Name:

Trade Name (dba):

(if no trade name, enter “NA”)

Borrower Contact:

Mr

Ms

First

MI

Last

Borrower Street:

Borrower Zip Code:

Borrower Phone #:

Borrower SSN #:

(must include SSN # for principal of borrower)

#

Employer EIN #:

(if available)

Borrower State:

(2 letter abbreviation)

Borrower County:

Borrower City:

Lender Name:

Lender ID #:

Loan Maturity:

(in months)

Loan Amount:

$

SBA Guaranty %:

%

Construction Amount:

$

New Construction?

Variable Interest Rate?

Variable Interest Rate: P+

%

Initial Bank Interest Rate:

%

Exporter?

Yes

No

New Business?	If Exporter, amount in exports applicant
Outstanding SBA Loan?	has projected loan will support:
Real Estate Collateral?

Rural

or

Urban

NAICS Code:

Number of Employees:

Number of Jobs Created:

Number of Jobs Retained:

Franchise?

Franchiser’s Name:

SBA USE ONLY:

Sole Proprietorship?				Partnership?			Corporation?			Other?
Veteran Status		1=Non-Veteran; 2=Other Veteran; 4=Service-Disabled Veteran
Gender		M=Male; F=Female
Race:		Amer. Ind./Alaska Native; Black/Afr.-Amer.; Asian; Native Haw./Pacific Islander; White
Ethnicity:		Hisp./Latino = 3 Not Hisp./Latino = (no code)
Owner #	% Owned		Veteran Code		Gender Code	Race Designation (Can choose more than one)		Ethnicity
									Please reference the above codes to complete this table for each
									20% or greater owner of the
									primary business associated with
									the borrower.

SBA Form 2276 (Part B) (11-05) Page 1 of 2

Supplemental Information for Gulf Opportunity Pilot

Borrower Name:

Use of Loan Proceeds	Amount
Purchase Land	$
Purchase Land and Improvements	$
Purchase Improvements	$
Construct a Building	$
Add an Addition to a Building	$
Make Renovations to a Building	$
Pay Off Interim Construction Loan	$
Pay Off Lender’s Interim Loan	$
Make Leasehold Improvements to a Building	$
Purchase Equipment	$
Purchase Fixtures	$
Purchase Inventory	$
Pay Trade or Accounts Payable	$
Pay Notes Payable	$
Pay Outstanding Debt	$
Purchase a Business	$
Purchase All Outstanding Stock	$
Pay SBA Loan	$
Working Capital	$
Pay the Guaranty Fee	$
Other	$
Total	$

Revolving Line of Credit?

Yes

No

The estimated burden for completing this form is 10 minutes. You will not be required to respond to any collection of information unless it displays a currently valid OMB Control Number. Comments on the burden should be sent to U. S. Small Business Administration (SBA), Chief, AIB, 409 3rd Street, SW, Washington, DC 20416 and Desk Officer for SBA, Office of Management and Budget, New Executive Office Building, Rom 10202, Washington, DC 20503. OMB Control Number 3245-0355. PLEASE DO NOT SEND FORMS TO OMB.

SBA Form 2276 (Part B) (11-05) Page 2 of 2