1919 SBA Express and Community Express Borrower Information F

SBA Express Information Collection

SBA Form Express 1919

SBA Express Information Collection

OMB: 3245-0348

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OMB Approval No.: 3245-0348

Effective Date: Expiration Date:


SBAEXPRESS & COMMUNITY EXPRESS BORROWER INFORMATION FORM


(To be completed by each proprietor, partner, officer, director, holder of 20% or more of voting stock of a corporate applicant, any other person, including a hired manager, who has authority to speak for and commit the borrower in the management of the applicant business).


APPLICANT BUSINESS NAME: _________________________________________________________________________

INDIVIDUAL NAME: ____________________________________ TITLE: _______________________________________


SOCIAL SECURITY NUMBER: __________________________ DATE OF BIRTH: _______________________________


PLACE OF BIRTH (City & State or Foreign Country): _________________________________________________________


CITIZENSHIP: ______________ IF NOT U.S., TYPE OF VISA OR ALIEN REGISTRATION: ______________________

ALL QUESTIONS MUST BE ANSWERED

(1) Are you presently under indictment, on parole or probation? Yes □ No □

(2) Have you ever been charged with or arrested for any criminal offense other than a minor vehicle

violation (including offenses which have been dismissed, discharged, or nolle prosequi)? Yes □ No □

(3) Have you ever been 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

vehicle violation? Yes □ No □

(4) Has an application for the loan you are applying for now ever been submitted to SBA under any

program? Yes □ No □

(5) Are you presently debarred, suspended, proposed for disbarment, declared ineligible, or

voluntarily excluded from participation in this transaction by any Federal department or agency? Yes □ No □

(6) If you are at least a 50% or more owner of applicant business, are you more than 60 days

delinquent on any obligation to pay child support arising under an administrative order, court

order, repayment agreement between the holder and a custodial parent, or repayment agreement

between the holder and a state agency providing child support enforcement services? Yes □ No □


If ‘YES’ to any above question, this application may not be submitted under SBAExpress procedures except according to the SBAExpress Program Guide, § 5.A.(5)(d). Please contact the local SBA office for assistance.


(7) Are any of your business’ products or services exported. or do you plan

to begin exporting as a result of this loan? Yes □ No □

(8) If ‘Yes’ to (7) above, estimated total export sales this loan will support: $________________________

(9) Is your business a franchise? Yes □ No □

(10) Have you, the business, or its affiliates ever requested government financing? Yes □ No □

If Yes, is any of the financing currently delinquent? Not Applicable □ Yes □ No □

Did any of this financing ever default and cause a loss to the government? Not Applicable □ Yes □ No □

(11) Have you, the business, or its affiliates had a previous SBA loan? Yes □ No □

If yes, is the loan either current or paid in full? Not Applicable □ Yes □ No □

(12) How many employees does your business have? _____________

(13) How many jobs will be created by the new loan? _____________ How many retained? _____________

(14) Did you or the business pay anyone to assist in preparation of this loan (packager, accountant,

lawyer, etc.)? Yes □ No □

(15) Will more than $10,000 of the loan proceeds be used for construction? Yes □ No □


The Small Business Administration is committed to insuring that all SBA programs are made available to business owners of all races. Furthermore, SBA has specified certain groups to target assistance (such as exporters or veterans). Please provide the information requested below. Your compliance is voluntary and will not affect the credit decision. It does help SBA determine how well certain groups are being served. Thank you for your cooperation.





(16) Are you:


Race: Amer. Ind./Alaska Native Black/Afr-Amer. Asian Native Haw./Pacific Islander White/Caucasian

(One or more boxes for race may be selected.)


Ethnicity: Hisp./Latino Not Hisp./Latino


(17) Are you a veteran of the United States Armed Forces?) Yes □ No □

If yes, are you a service-disabled veteran Yes □ No □


Please read the following restrictions below regarding use of federal financial assistance programs. If you understand them fully and agree to them, sign the end of this document.


SBA is 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. These are contained in Parts 112, 113, and 117 of Title 13 of the Code of Federal Regulations and in 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 automatically be released includes, among other things, statistics on our loan programs (individual borrowers are not identified in the statistics) and other information such as the name of borrowers (and their officers, directors, stockholder 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 be routinely made available to third parties.


Privacy Act (5 U.S.C. 552a) – Information Collection - Authorities: 15 USC 631, 634, & 636; 44 USC 3101; and PL 103-62. Principal Purposes: Determine character and repayment ability; verify criminal history disclosure; and investigate/confirm no current or potential SBA law violation. Routine Uses: Referral to Federal/State/local/foreign agency if current or potential legal violation indicated; to obtain credit reports on business, principals, and guarantors for loan origination/servicing/liquidation and for portfolio management and lender monitoring. See 69 Fed. Reg. 58598, 58617 (and as periodically amended) for more background and other routine uses. Nondisclosure: Not providing a social security number may not affect any right, benefit or privilege, but providing it assists SBA in obtaining accurate information on you. Name and other personal identifier disclosures are, however, required for a benefit.


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 financial assistance from SBA, including disaster assistance.


Executive Orders -- Floodplain Management and Wetland Protection (42 F.R. 26951 and 42 F.R. 26961) -- SBA discourages 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 due to a future flood.


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. Businesses can be forced to cease operations or be prevented from starting operations in a new facility. Therefore, 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 an applicant is certification that the OSHA requirements that apply to the applicant business have been determined and that the applicant, to the best of its knowledge, is in compliance. Furthermore, applicant certifies that it will remain in compliance during the life of the loan.


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 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.


Executive Order 11738 -- Environmental Protection (38 F.R. 251621) -- 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 environment protection legislation.


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 collect aggressively 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: (1) report the status of your loan(s) to credit bureaus, (2) hire a collection agency to collect your loan, (3) offset your income tax refund or other amounts due to you from the Federal Government, (4) suspend or debar you or your company from doing business with the Federal Government, (5) refer your loan to the Department of Justice or other attorneys for litigation, or (6) foreclose on collateral or take other action permitted in the loan instruments.





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. 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 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, railing, window 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 institutions structure where persons reside.


Right to Financial Privacy Act of 1978 (12 U.S.C. 3401) -- This is notice to you as required by the Right to 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 guaranty. 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 guaranteed loan. 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 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 a application for a loan, or concerning an approved loan or loan guarantee, as necessary to process, service or foreclose on a loan guaranty or collect on a defaulted loan guaranty.



I have read the items above and I understand them. I agree to comply, whenever applicable, with the hazard insurance, lead-based paint, civil rights or other limitations in this notice. I agree that all SBA loan proceeds will be used only for business related purposes as specified in the loan application and, to the extent feasible, to purchase only American-made equipment and products. I realize that the penalty for knowingly making a false statement or overvaluing security to obtain a guaranteed loan from SBA is that I may be fined up to $10,000 and/or be put in jail for up to 5 years under 18 USC §1001 and if submitted to a Federally insured institution, I may be fined up to $1,000,000 and/or be put in jail for up to 20 years under 18 USC §1014. I authorize the SBA Office of Inspector General to request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for programs authorized by the Small Business Act, as amended.





____________________________________________________________ ______________________________________________

SIGNATURE DATE























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 3245-0348. PLEASE DO NOT SEND FORMS TO OMB.

SBA Form 1919


File Typeapplication/msword
File Title.FA$TRAK BORROWER INFORMATION FORM
Author244-145
Last Modified ByCBRich
File Modified2007-04-30
File Created2007-04-30

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