Form 5 Disaster Business Loan Application

OMB No. 3245-0017
Exp XX-XXXX

U. S. Small Business Administration
DISASTER BUSINESS LOAN APPLICATION
FOR SBA INTERNAL USE ONLY

Physical Declaration Number

Filing Deadline Date

Economic Injury Declaration Number

Filing Deadline Date

FEMA Registration Number

SBA Application Number

(if known)

1.

ARE YOU APPLYING FOR:
Military Reservist EIDL (MREIDL)

Physical Damage -- Indicate type of damage

(complete the following)

Real Property

* Name of Essential Employee _________________________

Business Contents

* Employee's Social Security Number ______ - ____ - ______

Economic Injury (EIDL)
PLEASE PROVIDE ALL INFORMATION OR DOCUMENTATION REQUESTED IN THE ATTACHED FILING REQUIREMENTS.
* For information about these questions, see the attached Statements Required by Laws and Executive Orders.

2.

ORGANIZATION TYPE
Sole Proprietorship

Partnership

Limited Partnership

Limited Liability Entity

Corporation

Nonprofit Organization

Trust

Other: _______________

3.

APPLICANT'S LEGAL NAME

4. FEDERAL E.I.N. (if applicable)

5.

TRADE NAME (if different from legal name)

6. BUSINESS PHONE NUMBER (including area code)

7.

MAILING ADDRESS

Number, Street, and/or Post Office Box

8.

Business

9.

Temp

City

DAMAGED PROPERTY ADDRESS(ES)

(If you need more space, attach additional sheets.)
Number and Street Name

Home

Other ____________________________

County

State

Zip

State

Zip

Same as mailing address

City

County

PROVIDE THE NAME(S) OF THE INDIVIDUAL(S) TO CONTACT FOR:
Loss Verification Inspection

Information necessary to process the Application

Name

Name

Telephone Number

Telephone Number

10. ALTERNATE WAY TO CONTACT YOU (ie., cell #, fax #, e-mail, etc.)
Cell # □
Fax # □
E-mail □
Other □
Cell # □

Fax # □

E-mail □

11. TYPE OF BUSINESS:

12. DATE BUSINESS ESTABLISHED:

13. UNDER CURRENT MANAGEMENT SINCE:

14. BUSINESS PROPERTY IS:

15. AMOUNT OF ESTIMATED LOSS:

16. NUMBER OF EMPLOYEES:

If unknown, enter a question mark

□

17. IF YOU ARE A SOLE PROPRIETOR, ARE YOU A U.S. CITIZEN?
18. IF YOU HAVE ANY TYPE OF INSURANCE, PLEASE COMPLETE THE FOLLOWING:
Name of Insurance Company and Agent
Phone Number of Insurance Agent
SBA Form 5 (03-07) Ref SOP 50 30

Policy Number

YES

□

Other □

□ Leased

Owned

□

NO

19. OWNERS

(If you need more space attach additional sheets.)

Complete for each: 1) proprietor, or 2) limited partner who owns 20% or more interest and each
general partner, or 3) stockholder or entity owning 20% or more voting stock.

Name

Title/Office

SSN/EIN*

Marital Status

Date of Birth*

Place of Birth*

Mailing Address

City

Name

Title/Office

SSN/EIN*

Marital Status

Date of Birth*

Place of Birth*

Mailing Address

% Owned

E-mail Address

Telephone Number (including area code )
State
% Owned

Zip

E-mail Address

Telephone Number (including area code )

City

State

Zip

* For information about these questions, see the attached Statements Required by Laws and Executive Orders.

20. For the applicant business and each owner listed in item 19, please respond to the following questions, providing dates and
details on any question answered YES. (Attach an additional sheet for detailed responses.)

□
□

a. Has the business or a listed owner ever been involved in a bankruptcy or insolvency proceeding?
b. Does the business or a listed owner have any outstanding judgments, tax liens, or pending lawsuits against them?
c. Has the business or a listed owner ever been convicted of a criminal offense committed during and in connection with a riot
or civil disorder or ever been engaged in the production or distribution of any product or service that has been determined to
be obscene by a court of competent jurisdiction?
d. Has the business or a listed owner ever had or guaranteed a Federal loan or a Federally guaranteed loan?
e. Is the business or a listed owner delinquent on any Federal taxes, direct or guaranteed Federal loans (SBA, FHA, VA,
student, etc.), Federal contracts, Federal grants, or any child support payments?
f. Does any owner, owner's spouse, or household member work for SBA or serve as a member of SBA's SCORE, ACE, or
Advisory Council?

□
□
□
□

□ No
□ No

Yes
Yes

□ No
□ No
□ No
□ No

Yes
Yes
Yes
Yes

21. Is the applicant or any of the individuals listed in Item 19 currently, or have they ever been:
a) under indictment, on parole or probation; b) charged with or arrested for any criminal offense other than a minor motor vehicle violation,
including offenses which have been dismissed, discharged, or not prosecuted; or c) 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 motor vehicle violation?
Yes

If yes, Name

No

22. PHYSICAL DAMAGE LOANS ONLY. If your application is approved, you may be eligible for additional funds to cover the cost of

mitigating measures (real property improvements or devices to minimize or protect against future damage from the same type of disaster
event). It is not necessary for you to submit the description and cost estimates with the application. SBA must approve the mitigating
measures before any loan increase.
By checking this box, I am interested in having SBA consider this increase.

23. If anyone assisted you in completing this application, whether you pay a fee for this service or not, that person must print and sign
their name in the space below.
Name and Address of representative (please include the individual name and their company)
(Signature of Individual)

(Print Individual Name)

(Name of Company)

Phone Number (include Area Code)

Street Address, City, State, Zip

Fee Charged or Agreed Upon

Unless the NO box is checked, I give permission for SBA to discuss any portion of this application with the representative listed above.

NO

AGREEMENTS AND CERTIFICATIONS
On behalf of the undersigned individually and for the applicant business:
I authorize my insurance company, bank, financial institution, or other creditors to release to SBA all records and information necessary to process this
application.
I give my permission to release information in connection with this application to Federal, state, local, or private organizations that provide relief for disaster
related purposes.
I will not exclude from participating in, or deny the benefits of, or otherwise subject to discrimination under, any program or activity for which I receive Federal
financial assistance from SBA, any person on grounds of age, color, handicap, marital status, national origin, race, religion, or sex.
I will report to the SBA Office of the Inspector General, Washington, DC 20416, any Federal employee who offers, in return for compensation of any kind, to
help get this loan approved. I have not paid anyone connected with the Federal government for help in getting this loan.
All information in and submitted with this application is true and correct to the best of my knowledge. All financial statements submitted with this application
fully and accurately present the financial position of the business. I have not omitted any disclosures in these financial statements. This certification also
applies to any financial statements or other information submitted after this date. I understand that false statements may result in the forfeiture of benefits
and possible prosecution by the U.S. Attorney General (reference 18 U.S.C. 1001 and/or 15 U.S.C. 645).

SIGNATURE

TITLE
Sign in Ink

DATE