Form 1993 Federal Agency Comment Form

Federal Agency Comment Form

OMB Control #3245-0313

Small Business Administration – Office of the National Ombudsman
409 Third Street SW, Washington, DC 20416
P: (202) 205-2417 – F: (202) 481-5719

Exp. date 3/31/2007

Case #:_________

Instructions
1. Complete, sign and date this form. (Signature not required if completed at www.sba.gov/ombudsman).
2. Provide a brief written statement on the reverse side regarding the specific enforcement or compliance action taken against your organization by the
federal agency.
3. Submit copies of substantiating documentation, such as correspondence, citation, or notice (Note: Can be submitted separately from this form by fax
or mail. Make sure to reference your name or company's name with this information).
4. If your comments concern the IRS, you must also submit a completed IRS Tax Information Authorization Form 8821, available at
http://www.irs.gov/forms (Can be sent by fax or mail).
5. Fax, e-mail or send this form and requested information to: (1) Fax: (202) 481-5719; (2) E-mail: [email protected]; (3) Address: SBA,
Office of the National Ombudsman, 409 Third Street, SW, Washington, DC 20416.
Please Print

Organization/Company Name:
Address:
City:__________________________________________State:_____________ Zip:___________________________________
Phone:

Fax :

E-mail:

Contact Name:_______________________________________

Title:_____________________________________________

Please indicate your organization type:
Small Business
Not-for-Profit, Representing ________________________ Members
Small Government (population of less than 50,000)
List the federal agency with which you are having a problem:
Federal Agency Name:
Agency Contact person:
Agency Office/Division:

√ Did the federal agency listed above inform you of your right to contact the SBA Office of the National Ombudsman?
Yes

No

If not, how did you learn about this office?

_______________________________________________________________________________________________

Confidentiality / Disclosure
The Small Business Regulatory Enforcement Fairness Act (SBREFA), allows you to keep your identity and other information private, and limit
its access only to the Office of the Ombudsman (See 15 U.S.C. 657 (b) (2) (B)). However, by requesting confidentiality the federal agency may
not have sufficient information to investigate your specific problem, possibly delaying or preventing any potential resolution of your situation.
I request that my information be kept confidential.

Yes

No

(If yes, results may be limited.)

Signature:

Date:
Your signature authorizes the SBA Ombudsman to proceed on your behalf.
Pursue all legal options you believe are in your company’s best interest.
This process is not a substitute for legal action.

SBA FORM 1993 (3-07) Previous Editions Obsolete
Please Note: The estimated burden for completing this form is 45 minutes. You will not be required to respond to this information collection if a valid OMB
approval number is not displayed. If you have any questions or comments concerning this estimate or other aspects of this information collection, please contact
the U. S. Small Business Administration, Chief, Administrative Information Branch, Washington, D.C . 20416 and/or Office of Management and Budget, Clearance
Officer, Paperwork Reduction Project (3245-0313), Washington, D.C. 20503. PLEASE DO NOT SEND FORMS TO OMB.

Type or (print) your comments below:

SUBMIT

RESET