Form 1244 U.S. Small Business Administration Application for Secti

U.S. SMALL BUSINESS ADMINISTRATION
APPLICATION FOR SECTION 504 LOAN
OMB APPROVAL NO.: 3245-0071
EXPIRATION DATE: 12/31/2006

PART A
Name of CDC:
CDC Contact Person:
Name of Borrower:

Telephone No:

Name of Small Business Concern (SBC) (if different):
THE FOLLOWING MUST BE SUBMITTED: [Indicate if Attached (X) or Not Applicable (N/A).]
Instructions: If the CDC is using the Abridged Submission Method (ASM), the CDC must collect and retain in its file, but not submit to SBA, each Exhibit
marked with an asterisk (*).
1.

A credit memorandum, which includes CDC's credit analysis, a history and
description of the business and analysis of management ability, and
description of the qualifications and background of the principals involved
in day-to-day management of the business. Exhibit 1.

2.

"Eligibility Information Required for 504 Submission" form. Exhibit 2.

3.

Personal History Statement (SBA Form 912) for each officer and director
(regardless of ownership) and each proprietor, partner and stockholder with
20% or more ownership of the small business concern (SBC) and, if
different, each owner with 20% or more ownership of the EPC. Exhibit 3.

4. * Personal Financial Statement (SBA Form 413) current within 90 days for
each proprietor, partner or stockholder with 20% or more ownership of the
SBC, and, if different, each owner with 20% or more ownership of the
EPC, as well as copies of federal income tax returns for the last one year.
Exhibit 4.
5.

12.* The names of affiliated (through ownership or management control)
or subsidiary businesses as well as the last two fiscal year-end
financial statements and/or federal income tax returns for the last
two years (or three years, if the alternate 7(a) size standard is being
used). Exhibit 12.
13. If the business is a franchise, include a copy of the Franchise
Agreement and the Franchisor's Disclosure Statement that is
required by the Federal Trade Commission. Exhibit 13.
14.* A copy of key cost documents such as contractor costs, estimates,
vendor quotes for machinery and equipment, etc. as well as an
itemized listing of estimated "professional fees" that is summarized
in Part B, Section VII. Exhibit 14.
15. * If applicable, a copy of the existing or proposed lease agreement.
Exhibit 15. (Submit only at loan closing.)
16. An independent appraisal for project real estate as required by SOP
50-10. Exhibit 16.

{Reserved}. Exhibit 5.

6. * A balance sheet and income statement as well as federal income tax returns
for the previous two years for the SBC (or three years, if the alternate 7(a)
size standard is being used). If the SBC is a new business, provide a
proforma balance sheet with a description of assumptions attached.
Exhibit 6.

17. Environmental analysis, if applicable. Exhibit 17.
18.* An itemized listing of estimated "closing costs" summarized in Part B
Section VIII. Exhibit 18. (Submit only at loan closing.)

7. * A balance sheet and income statement dated within 120 days of the
application together with an aging of the accounts receivable and accounts
payable listed. Exhibit 7.

19.* A letter from the participating lender stating the terms and conditions
of its participation and the reason why it will not finance the entire
project. Exhibit 19.

8. * Where appropriate, a projected, annualized income statement for the first
two years after the loan with a description of assumptions attached.
Exhibit 8.

20.* A resolution from the partners, members, or Board of Directors of
the Borrower authorizing it to borrow. Exhibit 20. (Submit only at
loan closing.)

9. * For a new business, a monthly cashflow analysis for the first 12 months of
operation or for three months beyond the breakeven point (whichever is
longer) together with a description of assumptions attached. Exhibit 9.

21. USCIS verification of the USCIS status of any alien who is an owner
of 20% or more of the small business applicant or any person who
controls (as defined by SBA regulations and policies) the small
business applicant. Exhibit 21.

10.* A schedule of debts which includes the original date and amount, monthly
payment, interest rate, present balance owed, maturity, to whom payable,
and collateral securing the loan for each short-term and long-term loan that
the business currently has outstanding or has planned for the next 12
months (other than the 504 loan). Please indicate whether each loan is
current or delinquent. Exhibit 10.
11.* A schedule of any previous government financing received by the
applicant small business concern or any affiliated company of the
applicant as well as any associate (as defined by §120.10) or
principal of the applicant. Include the name of the agency, the
original date and amount, the outstanding balance, status of the loan
(current, delinquent, paid in full, or charged off), and collateral
securing the loan. Exhibit 11.

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22.* Credit reports for the SBC, its owner(s), and any affiliated company.
Exhibit 22.
23.* A completed SBA Form 159 (504) (Fee Disclosure Form and
Compensation Agreement) for costs incurred by the applicant to
third parties (attorney, accountant, etc.). Exhibit 23. (Submit only at
loan closing.)

U.S. SMALL BUSINESS ADMINISTRATION
APPLICATION FOR SECTION 504 LOAN
PART B
I.

Certified Development Company

Date of Application

Contact Person

Telephone No.

II. Borrower's Name

Employer ID Number

Name of Small Business Concern (SBC) if other than Borrower

Name of Principal in charge of the SBC

Telephone No.

SBC's Address

Street Address of Project (if different)

City

III.

EPC

County

State/Zip Code

City of Project

Location

Corp., Yrs Chartered

Check appropriate description

LLC

Type of Business

Exporter?

Yes____

1 - Urban
2 - Rural

New Business

NAICS Code Date Established

No____

State/Zip Code
Relocation

Yes
Minority Code

Woman-owned
Veteran-owned
Service Disabled Veteran-owned

If “yes”, estimated total export sales this loan will support $_________________.

Contact Person

Telephone No.

B. Name of Other Sources (including any other Federal sources)

Amount:

C. Name of Interim Lender (if different from IV.A.)

Amount:

Contact Person

Telephone No.

V. Purpose and Economic Impact

SBA USE ONLY

Approved by D.O.

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Date

Funding Approved

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No

Check if applicable:

IV. A. Name(s) of Participating Lender(s)

Amount:

No:

Existing Business

Partnership, No. Partners
Proprietorship

County of Project

Yes:

Date

VI.

A. Impact on Jobs

B.

1. Pre-project Employment

CDC's overall portfolio job ratio as of the date of the last Annual Report

C.

Economic Development Objectives
Community or Area Development
Public policy goals (check one below)
Rural development
Business district revitalization
Expansion of exports
Minority-owned business
Enhanced economic competition
Changes necessitated by Federal budget cutbacks
Business restructuring from Federally mandated policies affecting
the environment, employee safety or health.

2. Number of jobs to be created in the next two years
3. Number of jobs to be retained because of project
4. Total jobs to be created and retained (2 + 3)
5. Debenture Amt./$50,000
(504 projects only)
6. Does Project meet job requirement of 1 job per $50,000

Yes

Veteran-owned business
Woman-owned business

No

VII.

Proposed Uses of Funds

Amount Requested

VIII. Debenture Pricing (504)
A.
B.

A. Land (and purchase of existing building, if applicable): $
B. Building (new construction, remodeling, L/H improvement, etc.):$

C. Machinery & equipment (purchase, installation, etc.): $
D. Professional fees (appraiser, architect, legal, etc.):

$

E. Other Expenses (Contingency, interest on interim financing, etc.):
$
F. TOTAL PROJECT COST (Not including 504-related fees)

IX.

Sources of Funds (504 projects only)

$

SBA Share (
%) of Project Cost
$
Administrative Costs
1. Reserve Amount (Ax0.005)
$
2. Funding Fee (Ax0.0025)
$
3. CDC Processing Fee (Ax0.015)
$
4. Closing Costs
$
5. Total (B1 thru B4)
$
6. Underwriters Fee*
$
7. Total (B5 plus B6)
$
C.
Total Debenture Amount (A plus B7, rounded up to next
thousand)
$
D.
Balance to Borrower (C minus (A + B7)
$

Dollar Request

% Project Cost

XXX

XXX

A. Net Debenture (VIII.A.)
Gross Debenture (VIII.C.)

Requested

Maturity

Interest Rate

Lien Position

XXX

XXX

XXX

XXX

B. Private Sector

C. Other Financing (specify)

D. Borrower Injection
E. CDC Injection
F. TOTAL PROJECT FINANCING**
X.

100.00%

Source of Equity Injection

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XXX

XXX

XXX

*

Underwriters fee calculated as follows: For 20 year Debentures, the sum of a. and b.5 divided by 0.99600; round this number up the next highest
thousand; multiply this number by 0.00400. For 10 year Debentures, the sum of a. and b.5 divided by 0.99625; round this number up to the next highest
thousand; multiply this number by 0.00375.
** This does not include 504-related fees and costs.

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XI.

Financial Summary
Fiscal Year Ending

Statements (check one):

BALANCE SHEET

Audited

Review

ADJUSTMENTS

AS OF
Debits

Credits

ASSETS
Cash
Accounts Receivable
Inventory
Other
Total Current Assets
Fixed Assets
Other Assets
Total Assets
LIABILITIES & NET WORTH
Accounts Payable
Notes Payable
Taxes/Accruals
** Private Lender (cur. Portion)
SBA (current portion)
Other
Total Current Liabilities
Notes Payable
Private Lender (L-T portion)
SBA (L-T portion)
Other
Total Liabilities
Net Worth
Total Liab. & Net Worth
Ratio Analysis (use pro forma column)
*

XII.

NAICS Code

SBC

Industry Averages

Debt/Net Worth Ratio
Net Working Capital
Current Ratio
Other:
XIII. Balance Sheet Comments/Adjustments (e.g. goodwill, intangibles, etc.)
[Include here, or in credit memorandum (SBA Form 1244, Exhibit 1).]

*Notes Payable: include any existing current portion of long-term debt.
**For lender's share of 504 project only.
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SBC Use Only

Compilation

ADJ/FINANCIAL DATA
(Pro Forma)

XIV.

Income
Statement

Historical

Historical
Year

%

Current Interim

Year

%

Sales
Cost of Goods Sold
Gross Profit
G&A Expenses
Net before Taxes
Income Taxes
Net after Taxes
Break out of specific expenses: included in G + A above:
Depreciation
Interest
W/D& Officer Comp
Rent

XV.

Cash Flow Available for P&I

Existing

Projection

Year:

A. Earnings Before Taxes
B. + Depreciation
C. + Interest Expense
D. + Rent Savings, if any
E. + Other
1.
2.
F. Total Cash Flow

G. Existing Debt Service (P + I)
H. + Project Debt Service (P + I)
I. + Line of credit - principal
J. + Line of credit - Interest
K. + Other
L. Total Cash Requirements (G - K)
M. Cash Margin (F minus L)
N. Cash Flow Coverage Ratio

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

Year:

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

(F divided by L)
XVI.

Comments on Ability to Repay - (Include Working Capital Analysis and comments on credit history.)
[Include here, or in credit memorandum (SBA Form 1244, Exhibit 1).]

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Projection
%

%

XVII. List of Project Collateral

Cost or Net Book Value

Senior Lien

Appraised Value

(if available)

Land (and/or purchase of existing building)
Building (new construction, remodeling,
leasehold improvements, etc.)
Machinery and equipment (purchase,
installation, etc.)

Totals
Guarantor(s) and/or Owners

Personal Net Worth

Pledged Security (if applicable)

Analysis of Collateral Adequacy. (Include summary of environmental analysis, if any.)
[Include here, or credit memorandum (SBA Form 1244, Exhibit 1).]

XVIII. CDC Notifications
Has any member, officer, director or professional staff of CDC changed since last debenture request?
If so, has Form 1081 and resume been submitted to SBA?

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Yes:

No:

Yes:

No:

XIX. CDC Agreements and Certifications
The CDC agrees that if SBA approves this application, it will not for
at least two years after the disbursement of the debenture hire an
employee or consult anyone who was employed by the SBA during
the one-year period prior to the disbursement of the debenture.
The CDC certifies that it does not own any stock or equity in the
SBC and no officer, director, or person within a controlling group of
the CDC is an officer, director or holder of any direct or indirect
pecuniary interest in the SBC.
The CDC authorizes disclosure of all information submitted in
connection with this application to the financial institution agreeing
to participate with the SBA's guaranteed debenture or loan.
The CDC certifies that it will comply with 13 C.F.R. Sections 112,
113, and 117 which prohibit discrimination on the grounds of race,
color, sex, religion, marital status, handicap, age or national origin
by recipients of Federal financing assistance; and will require
appropriate reports and access to books and records. These
requirements are also applicable to anyone who buys or takes
control of the business. He/she realizes that if he/she does not
comply with these nondiscrimination requirements, SBA can call,
terminate, or accelerate repayment on his/her loan.

The CDC states, to the best of its knowledge and belief, that if any
funds have been paid or will be paid to any person for influencing or
attempting to influence an officer or employee of a Member of
Congress in connection with this commitment providing for the
United States to insure or guarantee a loan, it shall complete and
submit Standard Form-LL, "Disclosure Form to Report Lobbying,"
in accordance with this instructions. Submission of this statement is
a prerequisite for making or entering into this transaction imposed
by 31 U.S.C. 1352. Anyone who fails to file the required statement
shall be subject to a civil penalty of not less than $10,000 and not
more than $100,000 for each such failure.
The CDC in consideration for assistance from SBA hereby agrees
that it will comply with all Federal laws and regulations enforced to
the extent that they are applicable to such assistance, including
conditions set forth in this application.
The undersigned certifies that all information in this application and
the exhibits is true and complete to the best of his/her knowledge
and is submitted to SBA so that SBA can decide whether to approve
this application.

As consideration for any Management and Technical Assistance that
may be provided, the CDC waives all claims against SBA and its
consultants.
The CDC certifies that it has not paid anyone connected with the
Federal government for help in getting this financial assistance. It
also agrees to report to the SBA Office of Inspector General, 409 3rd
Str., SW, Washington, D.C. 20416 any Federal government
employee who offers in return for any type of compensation to help
get this application approved.

The CDC understands that whoever makes any statement knowing it
to be false, or whoever willfully overvalues any security for the
purpose of obtaining any loan, or extension thereof by renewal,
deferment of action, or otherwise, or the acceptance, release, or
substitution of security therefor, or for the purpose of influencing in
any way the action of SBA, or for the purpose of obtaining money,
property, or anything of value, under the Small Business Investment
Act, as amended, may be punished by a fine of not more than $5,000
or by imprisonment for not more than two years, or both, pursuant to
the Federal Law at 18 U.S.C. 1001.
The CDC certifies that the credit analysis has been reviewed and
approved by the CDC Board of Directors.

The CDC understands that it need not pay anyone to deal with SBA.
He/she has read SBA Form 159 which explains SBA policy on
representatives and fees.

Name of Development Company:

By:

Title:

Date:

Attested By:
PLEASE NOTE: The estimated burden for completing this form and exhibits is 2.08 for ASM submissions and 2.25 for non-ASM submissions. You are not
required to respond to any collection of information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to
U.S. Small Business Administration, Chief, AIB, 409 3rd St., S.W., Washington D.C. 20416 and Desk Officer for the Small Business Administration, Office
of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503. OMB Approval (3245-0071).
PLEASE DO NOT SEND FORMS TO OMB.

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U.S. SMALL BUSINESS ADMINISTRATION
PART C
Statements Required by Law and Executive Order
Federal executive agencies, including the Small Business Administration (SBA), are required to withhold or limit financial assistance, to
impose special conditions on approved loans, to provide special notices to applicants or borrowers and to require special reports and data
from borrowers in order to comply with legislation passed by the Congress and Executive Orders issued by the President and by the
provisions of various inter-agency agreements. SBA has issued regulations and procedures that implement these laws and executive orders,
and they are contained in Parts 112, 113, 116, and 117, Title 13, Code of Federal Regulations Chapter 1, or Standard Operating Procedures.
Freedom of Information Act (5 U.S.C. 552)
This law provides, with some exceptions, that SBA must supply information reflected in agency files and records to a person requesting it.
Information about approved loans that will be automatically released includes, among other things, statistics on our loan programs (individual
borrowers are not identified in the statistics) and other information such as the names of the borrowers (and their officers, directors,
stockholders or partners), the collateral pledged to secure the loan, the amount of the loan, its purpose in general terms and the maturity.
Proprietary data on a borrower would not routinely be made available to third parties. All requests under this Act are to be addressed to the
nearest SBA office and be identified as a Freedom of Information request.
Privacy Act (5 U.S.C. 552a)
A person can request to see or get copies of any personal information that SBA has in his or her file when that file is retrievable by individual
identifiers such as name or social security numbers. Requests for information about another party may be denied unless SBA has 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.
Under the provisions of the Privacy Act, you are not required to provide your social security number. Failure to provide your social security
number may not affect any right, benefit or privilege to which you are entitled. Disclosures of name and other personal identifiers are,
however, required for a benefit, as SBA requires an individual seeking assistance from SBA to provide it with sufficient information for it to
make a character determination. In determining whether an individual is of good character, SBA considers the person’s integrity, candor, and
disposition toward criminal actions. In making loans pursuant to section 7(a)(6) of the Small Business Act (the Act), 15 USC Section
636(a)(6), SBA is required to have reasonable assurance that the loan is of sound value and will be repaid or that it is in the best interest of
the Government to grant the assistance requested. Additionally, SBA is specifically authorized to verify your criminal history, or lack
thereof, pursuant to section 7(a)(1)(B), 15 USC Section 636(a)(1)(B). Further, for all forms of assistance, SBA is authorized to make all
investigations necessary to ensure that a person has not engaged in acts that violate or will violate the Act or the Small Business Investment
Act, 15 USC Sections 634(b)(11) and 687(b)(a). For these purposes, you are asked to voluntarily provide your social security number to
assist SBA in making a character determination and to distinguish you from other individuals with the same or similar name or other personal
identifier.
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, including business credit reports on the small business borrower and consumer credit reports and scores on
the principals of the small business and guarantors on the loan for purposes of originating, servicing, and liquidating small business loans and
for purposes of routine periodic loan portfolio management and lender monitoring. See, 69 F.R. 58598, 58617 (and as amended from time to
time) for additional background and other routine uses.
Right to Financial Privacy Act of 1978 (12 U.S.C. 3401)
This is notice to you as required by the Right of Financial Privacy Act of 1978, of SBA's access rights to financial records held by financial
institutions that are or have been doing business with you or your business, including any financial institutions participating in a loan or loan
guarantee. The law provides that SBA shall have a right of access to your financial records in connection with its consideration or
administration of assistance to you in the form of a Government loan or loan guaranty agreement. SBA is required to provide a certificate of
its compliance with the Act to a financial institution in connection with its first request for access to your financial records, after which no
further certification is required for subsequent accesses. The law also provides that SBA's access rights continue for the term of any approved
loan or loan guaranty agreement. No further notice to you of SBA's access rights is required during the term of any such agreement.
The law also authorizes SBA to transfer to another Government authority any financial records included in an application for a loan, or
concerning an approved loan or loan guarantee, as necessary to process, service or foreclose on a loan or loan guarantee or to collect on a
defaulted loan or loan guarantee. No other transfer of your financial records to another Government authority will be permitted by SBA
except as required or permitted by law.

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Flood Disaster Protection Act (42 U.S.C. 4011)
Regulations have been issued by the Federal Insurance Administration (FIA) and by SBA implementing this Act and its amendments. These
regulations prohibit SBA from making certain loans in an FIA designated floodplain unless Federal flood insurance is purchased as a
condition of the loan. Failure to maintain the required level of flood insurance makes the applicant ineligible for any future financial
assistance from SBA under any program, including disaster assistance.
Executive Orders -- Floodplain Management and Wetland Protection (42 F.R. 26951 and 42 F.R. 26961)
The SBA discourages any settlement in or development of a floodplain or a wetland. This statement is to notify all SBA loan applicants that
such actions are hazardous to both life and property and should be avoided. The additional cost of flood preventive construction must be
considered in addition to the possible loss of all assets and investments in future floods.
Occupational Safety and Health Act (15 U.S.C. 651 et seq.)
This legislation authorizes the Occupational Safety and Health Administration in the Department of Labor to require businesses to modify
facilities and procedures to protect employees or pay penalty fees. In some instances, the business can be forced to cease operations or be
prevented from starting operations in a new facility. Therefore, in some instances SBA may require additional information from an applicant
to determine whether the business will be in compliance with OSHA regulations and allowed to operate its facility after the loan is approved
and disbursed. Signing this form as borrower is a certification that the OSA requirements that apply to the borrower's business have been
determined and the borrower to the best of its knowledge is in compliance.
Civil Rights Legislation
All businesses receiving SBA financial assistance must agree not to discriminate in any business practice, including employment practices
and services to the public, on the basis of categories cited in 13 C.F.R., Parts 112, 113, and 117 of SBA Regulations. This includes making
their goods and services available to handicapped clients or customers. All business borrowers will be required to display the "Equal
Employment Opportunity Poster" prescribed by SBA.
Equal Credit Opportunity Act (15 U.S.C. 1691)
The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color,
religion, national origin, sex, marital status or age (provided that the applicant has the capacity to enter into a binding contract); because all or
part of the applicant's income derives from any public assistance program, or because the applicant has in good faith exercised any right
under the Consumer Credit Protection Act. The Federal agency that administers compliance with this law concerning this creditor is the
Federal Trade Commission, Equal Credit Opportunity, Washington, D.C. 20580.
Executive Order 11738 -- Environmental Protection (38 C.F.R. 25161)
The Executive Order charges SBA with administering its loan programs in a manner that will result in effective enforcement of the Clean Air
Act, the Federal Water Pollution Act and other environmental protection legislation. SBA must, therefore, impose conditions on some loans.
By acknowledging receipt of this form and presenting the application, the principals of all small businesses borrowing $100,000 or more in
direct funds stipulate to the following:
1.

That any facility used, or to be used, by the subject firm is not cited on the EPA list of Violating Facilities.

2.

That subject firm will comply with all the requirements of Section 114 of the Clean Air Act (42 U.S.C. 7414) and Section 308 of the
Water Act (33 U.S.C 1318) relating to inspection, monitoring, entry, reports and information, as well as all other requirements specified
in Section 114 and Section 308 of the respective Acts, and all regulations and guidelines issued thereunder.

3.

That subject firm will notify SBA of the receipt of any communication from the Director of the Environmental Protection Agency
indicating that a facility utilized, or to be utilized, by subject firm is under consideration to be listed on the EPA List of Violating
Facilities.

Debt Collection Act of 1982 Deficit Reduction Act of 1984 (31 U.S.C. 3701 et seq. and other titles)
These laws require SBA to aggressively collect any loan payments which become delinquent. SBA must obtain your taxpayer identification
number when you apply for a loan. If you receive a loan, and do not make payments as they come due, SBA may take one or more of the
following actions:
- Report the status of your loan(s) to credit bureaus
- Hire a collection agency to collect your loan
- Offset your income tax refund or other amounts due to you from the Federal Government
- Suspend or debar you or your company from doing business with the Federal Government
- Refer your loan to the Department of Justice or other attorneys for litigation
- Foreclose on collateral or take other action permitted in the loan instruments.

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Immigration Reform and Control Act of 1986 (Pub. L. 99-603)
If you are an alien who was in this country illegally since before January 1, 1982, you may have been granted lawful temporary resident
status by the United States Immigration and Naturalization Service pursuant to the Immigration Reform and Control Act of 1986 (Pub. L. 99603). For five years from the date you are granted such status, you are not eligible for financial assistance from the SBA in the form of a loan
or guaranty under section 7(a) of the Small Business Act unless you are disabled or a Cuban or Haitian entrant. When you sign this document,
you are making the certification that the Immigration Reform and Control Act of 1986 does not apply to you, or if it does apply, more than
five years have elapsed since you have been granted lawful temporary resident status pursuant to such 1986 legislation.
Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4821 et seq.)
Borrowers using SBA funds for the construction or rehabilitation of a residential structure are prohibited from using lead-based paint (as
defined in SBA regulations) on all interior surfaces, whether accessible or not, and exterior surfaces, such as stairs, decks, porches, railings,
windows and doors, which are readily accessible to children under 7 years of age. A "residential structure" is any home, apartment, hotel,
motel, orphanage, boarding school, dormitory, day care center, extended care facility, college or other school housing, hospital, group
practice or community facility and all other residential or institutional structures where persons reside.
Agreement of Nonemployment of SBA Personnel
I agree that if SBA approves this application, I will not for at least two years hire an employee or consult anyone who was employed by the
SBA during the one year period prior to the disbursement of the debenture.
Certification as to Payment for Financial Assistance
I certify: I have not paid anyone connected with the Federal government for help getting this financial assistance. I also agree to report to the
SBA Office of Inspector General, 409 Third Street S.W., Washington, D.C. 20416, any Federal government employee who offers in return
for any type of compensation to help get this application approved. I understand that I need not pay anybody to deal with SBA. I also
understand that a Certified Development Company may charge the applicant a percentage of the loan proceeds as set forth in SBA regulations
as a fee for preparing and processing the loan applications. I agree to pay for or reimburse SBA for the cost of any surveys, title or mortgage
examinations, appraisals, etc., performed by non-SBA personnel provided that I have given my consent.
Certification as to Non-relocation
Regulations issued by SBA prohibit the making of loans that will result in significant increase of unemployment in any area of the country
(13 CFR 120.881(a)). In the event that proceeds from this loan are used to provide a facility for relocation of the beneficiary small business
concern (including any affiliate, subsidiary or other business entity under direct, indirect or common control), the undersigned certifies that
such relocation will not significantly increase unemployment in the area of the original location.

Executive Order 12549, Debarment and Suspension (13 CFR 145)
1.

The prospective lower tier participant certifies, by submission of this loan application, that neither it nor its principals are presently
debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by
any Federal department or agency.

2.

Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective
participants shall attach an explanation to the loan application.

Conflicts of Interest
No overlapping relationship exists between the small business concern, including its associates, and the CDC, including its associates, or any
other lender providing financing for the project that could create an appearance of a conflict of interest as defined in 13 CFR 120.140 or
violate 13 CFR 120.851. No such relationships existed within six months of this application or will be permitted to exist while assistance is
outstanding.
Other Agreements and Certifications
I authorize disclosure of all information submitted in connection with this application to the financial institution agreeing to participate with
SBA's guaranteed debenture. I waive all claims against SBA and its consultants for any management and technical assistance that may be
provided. In consideration for assistance from the Small Business Administration, I hereby agree that I will comply with all Federal laws and
regulations to the extent that they are applicable to such assistance, including conditions set forth in this application. I, my spouse, or any
member of my household, or anyone who owns, manages, or directs the business or their spouses or members of their households do not
work for the SBA, Small Business Advisory Council, SCORE or ACE, any Federal agency, or the participating lender. If someone does, the
name and address of such person and where employed is provided on an attached page.

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Applicant Notifications
I or any of the officers of my company
have/
If so, I have attached copies of the proceedings.
I or my business

is/

have not been involved in bankruptcy or insolvency proceedings.

is not involved in any pending lawsuits. If so, I have attached a description.

Applicant's Acknowledgment
My signature acknowledges receipt of these Statements Required by Laws and Executive Orders, that I have read it and that I have a copy for
my files. My signature represents my agreement to comply with the requirements SBA makes in connection with the approval of my loan
request and to comply, whenever applicable, with the limitations contained in these Statements.
Certification as to Application Accuracy
All information in this application, including exhibits, is true and complete to the best of my knowledge and is submitted to SBA so that SBA
can decide whether to approve this application. Whoever makes any statement knowing it to be false, or whoever willfully overvalues any
security, for the purpose of obtaining any loan, or substitution of security therefore, or for the purpose of influencing in any way the action of
SBA, or for the purpose of obtaining money, property, or anything of value, under the Small Business Investment Act, as amended, may be
punished by a fine of not more than $5,000 or by imprisonment for not more than two years, or both, pursuant to the Federal law at 15 U.S.C.
645.
Whoever in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals or
covers up a material fact by any trick, scheme or device, or makes any false, fictitious or fraudulent statements or representations, or makes or
uses any false writing or documents knowing the same to contain any false, fictitious or fraudulent statement or entry may be fined up to
$10,000 or imprisoned for up to 5 years, or both, pursuant to the Federal law at 18 U.S.C. 1001.
(Each Proprietor, each General Partner, each Limited Partner or Stockholder owning 20% or more, and each Guarantor must sign. Each
person should only sign once.)
If Applicant is a proprietor or partnership, sign below:

If Applicant is an L.L.C. or corporation, sign below:

Name of Business

Corporate Name

By:

Date:

By:

Attested by:

Additional Proprietors, Partners, Stockholders or Guarantors as required.

Signature

Date

Signature

Date

Signature

Date

Signature

Date

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Date:

(seal, if required)