Sba Form 5 Disaster Business Loan Application

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Overview

Business App
Business Requirements

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Sheet 1: Business App

U. S. Small Business Administration

OMB No. 3245-0017 Exp. 08-2010

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:

Physical Damage -- Indicate type of damage

Military Reservist EIDL (MREIDL)

(complete the following)

Real Property

Business Contents

* Name of Essential Employee _________________________

* 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

Business

Home

Temp

Other ____________________________

Number, Street, and/or Post Office Box

City

County

State

Zip

8.

DAMAGED PROPERTY ADDRESS(ES)

(If you need more space, attach additional sheets.)

Same as mailing address

Number and Street Name

City

County

State

Zip

9.

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 □

Other

□

11.

TYPE OF BUSINESS:

12.

DATE BUSINESS ESTABLISHED:

13.

UNDER CURRENT MANAGEMENT SINCE:

14.

BUSINESS PROPERTY IS:

□

Owned

□

Leased

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?

□

YES

□

NO

18.

IF YOU HAVE ANY TYPE OF INSURANCE, PLEASE COMPLETE THE FOLLOWING:

Name of Insurance Company and Agent

Phone Number of Insurance Agent

Policy Number

SBA Form 5 (08-07) Ref SOP 50 30

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

% Owned

E-mail Address

SSN/EIN*

Marital Status

Date of Birth*

Place of Birth*

Telephone Number (including area code)

Mailing Address

City

State

Zip

Name

Title/Office

% Owned

E-mail Address

SSN/EIN*

Marital Status

Date of Birth*

Place of Birth*

Telephone Number (including area code)

Mailing Address

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?

□

Yes

□

No

□

Yes

□

No

b.

Does the business or a listed owner have any outstanding judgments, tax liens, or pending lawsuits against them?

□

Yes

□

No

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?

□

Yes

□

No

d.

Has the business or a listed owner ever had or guaranteed a Federal loan or a Federally guaranteed loan?

□

Yes

□

No

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?

□

Yes

□

No

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?

□

Yes

□

No

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

No

If yes, Name

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

DATE

Sign in Ink

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Sheet 2: Business Requirements

U. S. Small Business Administration

DISASTER BUSINESS LOAN APPLICATION

Filing Requirements

For ALL Disaster Business Loans, the following requirements (1 through 4) must be submitted with your Disaster Loan Application Package.

1.

Copies of the applicant's 3 most recent Federal Income Tax Returns, including all schedules. If this is a new business that has not filed 3 Federal Tax Returns, submit the ones you have filed. Also, complete and sign the attached Tax Information Authorization (IRS Form 8821). Sole proprietors need only submit the IRS Form 8821. We will contact you if we need any additional information (i.e., forecasts, etc.).

2.

A current (dated within 90 days of application) business balance sheet (you may use the attached Personal Financial Statement (SBA Form 413) if you are a sole proprietorship), a current profit and loss statement, and a current schedule of liabilities. (We attached a sample schedule of liabilities (SBA Form 2202) for your convenience.)

3.

For: 1) each proprietor; or 2) each limited partner who owns 20% or more interest and each general partner; or 3) each stockholder or entity owning 20% or more of voting stock, a current (dated within 90 days of application) personal financial statement (you may use SBA Form 413 for this purpose). Entities (except sole proprietorships) must also submit a complete copy, including all schedules, of the entity's most recent Federal Income Tax Return.

4.

A complete copy, including all schedules, of the latest Federal Income Tax Return for each affiliate. Affiliates include, but are not limited to business parents, subsidiaries, or other businesses with common ownership or management. An authorized individual must complete and sign the attached IRS Form 8821 for each affiliate.

Additional requirements for PHYSICAL DAMAGE

1.

Please prepare and have available for SBA's Loss Verifier a brief description of damage to real estate and business contents.

2.

If your insurance covers all or a part of this loss (regardless of the current status of your claim), please provide the name and telephone number of your agent and/or claims adjuster. Also, include the policy number and the name of the insurance company. If available, include a copy of your proof of loss and a copy of the declaration page of your insurance policy.

Additional requirements for ECONOMIC INJURY

1.

Please submit the attached SBA Form 1368, Additional Filing Requirements - Economic Injury Disaster Loan (EIDL).

2.

Please provide a brief explanation of the economic loss caused by the declared disaster. Include an explanation of how the loan funds would be used.

IF SBA APPROVES YOUR LOAN, WE MAY REQUIRE ADDITIONAL INFORMATION BEFORE LOAN CLOSING. WE WILL ADVISE YOU, IN WRITING, OF WHAT DOCUMENTS WE NEED.

IF SBA APPROVES YOUR LOAN, WE MAY REQUIRE ADDITIONAL INFORMATION BEFORE LOAN CLOSING. WE WILL ADVISE YOU, IN WRITING, OF WHAT DOCUMENTS WE WILL NEED.

Additional requirements for Military Reservist Economic Injury (MREIDL) on back page

Additional requirements for Military Reservist Economic Injury (MREIDL)

Military Reservist Economic Injury (MREIDL) - Waiting Period: A small business is eligible to apply for assistance during a period beginning on the date an essential employee is ordered to active duty and ending on the date 90 days after the date the essential employee is discharged or released from active duty.

1.

Please provide:

a.

A copy of the essential employee's "orders" for active duty (showing the date of call-up and date released from active duty, if known).

b.

A statement from the business owner that the reservist is essential to the successful day-to-day operations of the business (detailing the employee's duties and responsibilities and explaining why these duties cannot be completed in the essential employee's absence).

c.

A certification by the essential employee that he or she concurs with the statements in "b" above.

d.

A written explanation and financial estimate of how the call-up of the essential employee for active duty has or will result in substantial economic injury to the business. (Provide monthly sales figures beginning 3 years prior to the call up and continuing through the most recent month available. You may use SBA Form 1368 for this purpose.)

e.

A description of the steps the business is taking to alleviate the substantial economic injury.

f.

A certification from the business owner that the essential employee will be offered the same or a similar job upon return from active duty.

IF SBA APPROVES YOUR LOAN, WE MAY REQUIRE ADDITIONAL INFORMATION BEFORE LOAN CLOSING. WE WILL ADVISE YOU, IN WRITING, OF WHAT DOCUMENTS WE NEED.