Form SBA FORM 2294 SBA FORM 2294 Alternative Creditworthiness Assessment

OMB Control Number 3245-0359

Expiration Date XX-XXXX

SMALL BUSINESS ADMINISTRATION

Alternative Creditworthiness Assessment

Purpose of this Form

Pursuant to Section 846 of the Consolidated Appropriations Act, 2006 (P.L. 109-115) U.S. Government agencies must assess the creditworthiness of all new travel card applicants prior to issuing a card. Creditworthiness assessments are an important internal control to ensure that charge cardholders are financially responsible. The information collected on this form is only required in the circumstance when obtaining a credit score is not possible. Failure to furnish requested information may delay or prevent action on your application for employment.

Providing Social Security Numbers is purely voluntary. Social Security Numbers are used to keep records accurate because other people may have the same name and birth date. Executive Order 9397 also asks Federal agencies to use this number to help identify individuals in agency records.

Disclosure of Information

The information you give us is for the purpose of making a Creditworthiness assessment to determine whether you possess a satisfactory credit history; we will protect it from unauthorized disclosure. The collection, maintenance, and disclosure of credit information are governed by the Privacy Act. If you are not offered employment this form will be destroyed at the end of the employment selection process. However, if you become an employee of the Agency this form will become part of your personnel file and will be maintained in a Privacy Act system of records. The Small Business Administration has published notice in the Federal Register at 69 F.R. 58598 describing the system of records in which your records will be maintained. You may obtain a copy of the notice from the person who gave you this form. The information on this form and information that we collect during an assessment may be disclosed without your consent as a routine use as permitted by the Privacy Act (5 USC 552a (b). Some of these routine uses include:

(1) To a Congressional office when the office is inquiring on the individual’s behalf;

(2)To Agency volunteers, interns, grantees, experts and contractors who have been engaged by the Agency to assist in the performance of a service related to this system of records and who need access to the records in order to perform this activity.

(3) To the Department of Justice (DOJ) when any of the following is a party to litigation or has an interest in such litigation, and the Agency determines the records are relevant and necessary to the litigation: (1) The agency, or any of its components; (2) Any employee of the agency in his or her official capacity, or in an individual capacity where the DOJ has agreed to represent the employee; or (3) The United States Government, where the agency determines that litigation is likely to affect the agency or any of its components.

(4) In a proceeding before a court, or adjudicative body, or a dispute resolution body before which the agency is authorized to appear or before which any of the persons or entities listed above is a party to, or has an interest in the litigation; and the Agency determines that such records are relevant and necessary to the litigation.

If you have questions or concerns regarding the disclosure of information or routine uses under the Privacy Act, you may contact the Freedom of Information/Privacy Acts Office, 409 Third Street, SW, Washington, DC 20416 or [email protected].

PLEASE NOTE: The estimated burden for completing this form is 15 minutes per response. You are not required to respond to any collection of information unless it displays a current valid OMB approval number. Comments on the burden should be sent to U.S. Small Business Administration, Chief, AIB, 409 3^rd St., SW, Washington, DC 20416 and Desk Officer for the Small Business Administration, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, DC 20503. OMB Approval (3245-0359). PLEASE DO NOT SEND FORMS TO OMB.

1. YOUR FINANCIAL RECORD

In the last 7 years, have you filed a petition under any chapter of the bankruptcy code (to include Chapter 13)? Y N

In the last 7 years, have you had your wages garnished for any reason? Y N

In the last 7 years, have you had any property repossessed for any reason? Y N

In the last 7 years, have you had a lien placed against your property for failing to pay taxes and other debts? Y N

In the last 7 years, have you had any judgments against you that have not been paid? Y N

If you answered “Yes” to any of the questions listed above, provide the information requested below:

Month/Year	Type of Action	Amount	Name Action Occurred Under	Name/Address of Court or Agency Handling Case	State	ZIP Code

YOUR FINANCIAL DELINQUENCIES

In the last 7 years, have you been over 180-days delinquent on any debt(s)? Y N

Are you currently over 90 days delinquent on any debt(s)? Y N

If you answered “yes” to either of the questions above, provide the information requested below:

Incurred Month/Year	Satisfied Month/Year	Amount	Type of Loan or Obligation and Account Number	Name/Address of Creditor or Obligee	State	ZIP Code

SBA Form 2294 (03-07)

PUBLIC RECORD CIVIL COURT ACTIONS

In the last 7 years, have you been a party to any public record civil court actions not listed elsewhere on this form? Y N

If you answered “yes”, provide the information about the public record civil court action requested below:

Month/Year	Nature of Action	Result of Action	Name of Parties Involved	Court (include City and county/country if outside U.S.)	State	ZIP Code

Certification That My Answers Are True

My statements on this form, and any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I understand that a knowing and willful false statement on this form can be punished by fine or imprisonment or both. (See section 1001 of title 18, United States Code).

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PRINTED NAME SOCIAL SECURITY NUMBER

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SIGNATURE DATE