SBA Form 994 Application for surety bond guarantee assistance to be c

OMB Control No: 3245-0007

Expiration Date: 05-31-2008

U.S. SMALL BUSINESS ADMINISTRATION

APPLICATION FOR SURETY BOND GUARANTEE ASSISTANCE

TO BE COMPLETED BY SMALL BUSINESS

PART I: BUSINESS INFORMATION (Completed for initial application and if information changes.)

Business Name and Business Trade Name

Tax I.D. No. or SSN

Business Address

Tel. No (Include Area Code)

Fax No. (Include Area Code)

City

County

State

Zip

Number of Employees (Including subsidiaries and affiliates)

Type of Organization  Proprietorship  Partnership  Corporation  Joint Venture Type of Corp ___________________________

Date Business Established

Average Annual Receipts Over last 3 years, Including Affiliates

Largest previous work program undertaken Total Dollar Value: __________ Total Number of Contracts: ________

Type of Business

NAICS Code

Applicant:  is  is not an SBA 8(a) Certified Contractor  is  is not an SBA Certified HUB Zone Contractor  has  has not had an SBA loan. If so, Loan # ________________________________  has  has not received SBA Surety Bond Guarantee Assistance under another business name. If so, Business Name _________________________________ Tax ID or SSN __________________________________  has  has not defaulted on any previous surety bonds (SBA or other)  has  has not ever failed to complete a job If so, include pertinent information in comments section.  is  is not requesting Business Development Assistance

PART II: Principal Information (Completed for initial application and if information changes.)

MANAGEMENT (Proprietor, partners, officers, directors, all holders of outstanding stock – 100% of ownership must be shown) Use separate sheet if necessary

Name and Social Security Number and Position/Title

Complete Address and Telephone Number

% Owned

*Gender

Veteran  Yes  No

Service Disabled 

Race*: American Indian/Alaska Native Black/African American Asian Native Hawaiian/Pacific Islander White/Caucasian

Ethnicity *Hispanic/Latino  Not Hispanic/ Latino 

*This data is collected for statistical purposes only. It has no bearing on the credit decision. Disclosure is voluntary. One or more boxes for race may be selected.

Name and Social Security Number and Position/Title

Complete Address and Telephone Number

% Owned

*Gender

Veteran  Yes  No

Service Disabled 

Race*: American Indian/Alaska Native Black/African American Asian Native Hawaiian/Pacific Islander White/Caucasian

Ethnicity *Hispanic/Latino  Not Hispanic/ Latino 

*This data is collected for statistical purposes only. It has no bearing on the credit decision. Disclosure is voluntary. One or more boxes for race may be selected.

SBA Form 994 (5-08) Previous Editions are Obsolete

PART III: CONTRACT INFORMATION (Completed for each bid and final bond guarantee)
 Bid Bond	Estimated Contract Amount				Bid Date and Time
 Final Bond	Contract Amount	Start Date			Completion Date
Project Type  Construction  Service  Supply  Other_____________ Project Description:		Project Location
Name and Address of Obligee		Obligee Type:  Federal  State  Local  Private  Special District
Applicant Business is  Prime  Subcontractor on this project		Percentage of work subcontracted:
Liquidated Damages  Weekdays Dollar Amount: __________________  Calendar Day		Project: Similar to previous work  Yes  No Pertains to an 8(a) contract  Yes  No
Have you updated SBA Form 994F in the last 3 months?  Yes  No If not, please update.		Have you started work on the project?  Yes  No If so, please complete SBA Form 991.
PART IV: AGREEMENTS, CERTIFICATIONS AND COMMENTS (Completed for Initial Applications and Each Bid and Final Bond Guarantee.)
Agreements: In consideration of assistance from the SBA, I agree to comply with the nondiscrimination requirements of Title 13, Code of Federal Regulations, Part 113 and Executive Order 11246. I agree to pay the applicable contractor fee and submit my check with any application for a final (payment or performance) bond. Certification: I certify: A bid, payment, or performance bond is required by the bid solicitation or the original contract for this project Applicant business has attempted and failed to obtain the required bonds without SBA’s guarantee. Percentage of work that applicant has subcontracted (see Part III) is accurate. Applicant is not delinquent on any Federal debt or Federally Guaranteed Debt. All information in this application and that relates to this application which has been submitted to SBA, any agent, broker, or surety company, is complete and accurate to the best of my knowledge. If Parts I, II and V of this application, and/or “Statement of Personal History” (SBA Form 912) have previously been submitted in connection with an earlier application, I have reviewed that information and certify that it either remains complete and accurate or that I have submitted a revised application Parts I, II or V or revised SBA Form 912 with complete and accurate information to the best of my knowledge. I authorize any agent, broker, surety company, or financial institution in possession of credit, financial or work experience information concerning the undersigned applicant and the applicant’s business to release the same to SBA, in order that SBA may evaluate the same for the purpose of bond guarantee assistance.
Comments
I understand that knowingly making a false statement or submitting false information is a violation of Federal law and could result in criminal prosecution or civil penalties under 18 U.S.C. §§ 287, 371, 1001, 15 U.S.C. § 645, or 31 U.S.C. § 3729
Principal’s Signature (Applicant)
Title			Date	SBG Number

SBA Form 994 (5-08) Previous Editions are Obsolete

Part V: “STATEMENTS REQUIRED BY LAW AND EXECUTIVE ORDER AND CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY, AND VOLUNTARY EXCLUSION” (Completed for Initial Application and with any Ownership Changes)

APPLICANT’S CERTIFICATION

By my signature, I certify I have read and received a copy of the “STATEMENTS REQUIRED BY LAW AND EXECUTIVE ORDER” which was attached to this application. My signature represents my agreement to comply with the approval of my request for SBG Assistance and to comply whenever applicable with the hazard insurance, lead-based paint, civil rights or other limitations in this notice.

I also certify that my personal history and financial information submitted to SBA electronically, as part of my application is current, accurate, and complete.

Business Name: _____________________________________________________________________________________________________

By: ______________________________________________________________ ____________________________________________________

Signature Title Date

Each Proprietor, each General Partner, each Limited Partner or Stockholder owning 20% or more, each Guarantor, and the spouse, when applicable, of each of these must sign. Each person should sign only once. The person signing on behalf of the business must also sign individually.

_______________________________________________________________ _____________________________________________________

Signature and Title Date

_______________________________________________________________ _____________________________________________________

Signature and Title Date

_______________________________________________________________ _____________________________________________________

Signature and Title Date

_______________________________________________________________ _____________________________________________________

Signature and Title Date

_______________________________________________________________ _____________________________________________________

Signature and Title Date

_______________________________________________________________ _____________________________________________________

Signature and Title Date

_______________________________________________________________ _____________________________________________________

Signature and Title Date

SBA Form 994 (5-08) Previous Editions are Obsolete

PLEASE READ, DETACH, AND RETAIN FOR YOUR RECORDS

STATEMENTS REQUIRED BY LAW AND EXECUTIVE ORDER

Federal executive agencies, including the Small Business Administration (SBA), are required to withhold or limit

assistance, to impose special conditions on approved guarantee agreements, to provide special notices to applicants and to require special reports and data from applicants 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 113 and 117, Title 13, Code of Federal Regulations Chapter I, 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 SBG guarantee agreements that will be automatically released includes, among other things, statistics on the SBG programs (individuals are not identified in the statistics) and other information such as the names of small businesses (and their officers, directors, stockholders or partners), the amount of the SBG guarantee agreement. Proprietary data on an applicant 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. Before any bonds may be guaranteed by SBA pursuant to Section 411 of the Small Business Investment Act (the Act), 15 USC 694b, SBA is required to have a reasonable expectation that the applicant will perform the contract for which the bond is sought, and that the terms of and conditions of the bond are reasonable in the light of the risks involved and the extent of the surety’s participation. 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 or the Small Business Investment Act, 15 USC Section 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 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, foreign, charged with responsibility for or otherwise involved in investigation, prosecution, enforcement or prevention of such violations. (See, 69 F.R. 58598 (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 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. 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 SBG guarantee agreement.

The law also authorizes SBA to transfer to another Government authority any financial records included in an application for a SBG guarantee, or concerning an approved SBG guarantee, as necessary to process or service the guarantee. No other transfer of your financial records to another Government authority will be permitted by SBA except as required or permitted by law.

SBA Form 994 (5-08) Previous Editions are Obsolete

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.

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 procedure to protect employees or pay penalty fees. In some instance 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 SBG guarantee agreement is approved. Signing this form as an applicant is a certificate that the OSA requirements that apply to the applicant’s business have been determined and the applicant to the best of its knowledge is in compliance.

Civil Rights Legislation

All businesses receiving SBA 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 113, and 117 of SBA Regulations. This includes making their goods and services available to handicapped clients or customers. All businesses receiving assistance will be required to display the “Equal Employment Opportunity Poster” prescribed by SBA.

Debt Collection Act of 1982 Deficit Reduction of 1984 (31 U.S.C. 3701 et seq. and other titles)

These laws require SBA to aggressively collect any fee payments which become delinquent. SBA must obtain your taxpayer identification number when you apply for assistance. If you receive a SBG guarantee, and do not pay the related fee assistance, SBA may take one or more of the following actions:

• Report the status of your payment delinquency to credit bureaus

• Hire a collection agency to collect your fee

• 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 fee to the Department of Justice or other attorney for litigation

• Foreclose on collateral or take other action permitted

Immigrations 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. 99-603). 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.

Executive Order 12549, Debarment and Suspension (13 C.F.R. 145)

1. The prospective lower tier participant certifies, by submission of this proposal, that neither its 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 participant shall attach an explanation to this proposal.

SBA Form 994 (5-08) Previous Editions are Obsolete

SURETY BOND GUARANTEE APPLICATION PROCEDURES

1. Applicant must contact a surety agency which participates in SBA’s Surety Bond Guarantee Program. A list of participating surety agencies, SBA Area Office contacts, and instructions to apply for SBG assistance are on the Office of Surety Guarantees website at www.sba.gov/OSG/

2. The applicant must submit required forms and information to the surety agent of choice.

3. If the application is for final (performance and/or payment) bonds, it must be accompanied by the Contractor Fee check payable to SBA (or U.S. Small Business Administration)

4. Upon completion of favorable underwriting, surety forwards all required documents, to the appropriate SBA area office.

5. The SBA Surety Bond Guarantee staff reviews the application, makes final determination, and notifies surety of its decision. SBA returns the countersigned Guarantee Agreement to the surety. If SBA declines to issue the guarantee, the check for the Contractor Fee is also returned to the surety.

6. If any adverse information develops subsequent to SBA’s approval of the bond guarantee, surety may decline to issue the bonds.

PLEASE NOTE: The estimated burden for completing this form is 6 minutes per response. 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 3^rd 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 (3245-007). PLEASE DO NOT SEND FORMS TO OMB.

SBA Form 994 (5-08) Previous Editions are Obsolete

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