Sba Form 5c Disaster Home Application

Disaster Home Loan Application

ELA Home Screen 3245-0018

Disaster Home Loan Application

OMB: 3245-0018

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 3245-0018 can be found here:

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U.S. Small Business Administration
Electronic Disaster Loan Application

Federal Disaster Loans for Homeowners,
Renters, and Businesses of all Sizes
Continue

Home 3245-0017

09/12/2008

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What is the SBA Disaster Loan Program?
In the wake of hurricanes, floods, earthquakes, wildfires, tornadoes and other
disasters, the SBA is the primary source of money from the Federal government for
long-term recovery assistance. For disaster damage to private property owned by
individuals, families and businesses not fully covered by insurance, the basic form
of Federal assistance is low-interest, long-term disaster loans from the SBA.
Property owners usually have some insurance coverage, but often it does not cover
all losses or even the type of hazard, which caused the damage. This leaves
individuals and businesses with significant uninsured costs.
Most people cannot afford to pay for expensive disaster repairs out-of-pocket.
SBA disaster loans make recovery possible for the majority of borrowers.

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Welcome to SBA's Electronic Loan Application (ELA)
• The recommended browser for this site is Internet Explorer 6.0 or later.
• The first step in the ELA process is to register as a user of the SBA disaster
assistance site. At the end of the registration process, you will be asked to accept
our Statements Required By Laws and Executive Orders. Once you accept them,
a 10 digit Reference Number will appear at the bottom of the screen. Record
this number for future correspondence with the SBA or if you need to return to
complete your application. If you exit the system before accepting the Statements
Required By Laws and Executive Orders, you information will not be saved and you
will need to start a new application.
• If you have already completed an application and received a decision on your
application or your application has been withdrawn, please do not apply again.
Contact our Customer Service Center at (800) 659-2955. Customers with speech
or hearing disabilities may phone (800) 877-8339.

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Navigating the ELA
• For each screen, if you do not enter all the required information or the information you enter is not in
the correct format, you will not be able to go to the next screen. We will display a message in red to
identify missing information or format errors. You must enter the missing information and correct
errors to continue.
• After you complete each screen, select Next to continue.
• To go back, select Previous. If you have not completed the section, the ELA will take you back one
screen at a time.
If you select Previous the information you entered on the current screen will
be lost. You only lose information on the current screen.
• Do NOT use the Back and Forward navigation buttons on the tool bar of your Internet browser.
Always use Next and Previous to move from screen to screen. Using the Back and Forward buttons
will likely cause an application error. If an application error occurs, you must exit the ELA and log in
again.
• You can exit the ELA at any time by selecting the Exit button. When you select Exit, your session
closes properly, your data is saved, and you are logged out of the ELA.

Important Note: Do Not select the X in the upper right-hand corner of the screen to exit. If you select the
X to close the browser, your session will not be properly closed and you will not be able to log back in for
another 15 minutes.
In order to print documents from the ELA, you will need Adobe Reader. If you do not have Adobe Reader
installed on your computer, please click here to install Adobe Reader free.
If you need additional assistance on completing the ELA, select the help button at any time to guide you
through the process.

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* Do you accept the terms of use?
I Accept
I Do Not Accept

Are you a registered user of the SBA Disaster Assistance
Account Site?
Yes, I am a registered user on the SBA Disaster Assistance Account Site.
No, I'm a new user.

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Home/Personal Property Loan Application

Business Loan Application

Filing Requirements - Home
Identity Information
-Social Security Number for you and for all co-applicants
-FEMA Registration Number, if available *
Deed or Lease Information, if available
-Copy of your deed
-Mortgage holder’s name, address, telephone number
-Landlord’s name, address and telephone number
-Copy of the title to your damaged mobile home, if available
-Copy of the current registration to any damaged automobile or other vehicle, if available
Insurance Information - Coverage for This Loss, if available
-Insurance policy (declaration page)
-Settlement information
-If you do not have your insurance policy or settlement information, you may be asked to provide the
name, address and telephone number of your insurance agent
Financial Information
-Copies of your (and your spouse's, if you are married) most recently filed Federal Income Tax
Return, if available
-If you have changed employment within the past 2 years, a copy of a current (within 1 month of the
application date) pay stub
-If you are self-employed, current profit and loss statement and balance sheet, if available
-Your current bank statements, investment mortgage information, business and farm records, stocks
and bonds, and other investment records
-Creditors’ names (include all mortgages, credit cards, installment loans, personal loans, vehicle
loans)
-Monthly payments
-Balances owed

Miscellaneous Information, if available
-Account information on existing direct or guaranteed Federal and SBA loans
-Details on delinquent taxes
-Details on bankruptcies
-Details on any outstanding judgments and pending lawsuits

*In a disaster declared by the President, all disaster victims should
register with FEMA by calling (800) 621-3362 ), or (800) 462-7585 for people
with speech or hearing disabilities.
Based on the information you provide, we will generate a list of additional
filing requirements necessary for us to process your application.
Print

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Website Registration * Indicates Required Field
* First Name

* Last Name

* Social Security Number

Suffix

* Date of Birth
MM/DD/YYYY

###-##-####

Address
Street

* Street #

Post Office Box

Rural Route

* Street Name

Suffix

* Street Type

Unit/Suite/Number

Address Line 2
* City

* State

Phone Number (landline)

* Zip Code

Cell Phone Number

* County
E-Mail Address

YOU MUST ENTER A PHONE NUMBER ABOVE FOR THE AUTHENTICATION METHOD YOU
HAVE SELECTED!

Please select an authentication method below. Authentication methods are how we
make sure that no one else is using your identity to access your account. We will send
you a pass code - a special code you enter to gain access.
* Pass Code Delivery Method
Text message Delivery to Cell Phone
We will send a pass code to your cell phone. (Your cell phone must support SMS text messaging)
Voice Delivery to Home Phone
The system will call you on your landline telephone and read a pass code to you.
Voice Delivery to Cell Phone
The system will call you on your cell phone and read a pass code to you.

*Create Your User Name (Must be at least 6 characters)
Your User Name does not meet the requirements for User
Name format. Please try again.
Must be at least 8 characters and must contain at least three of the
*Create Your Password following items: one uppercase letter, one lower case letter, one number,
one special character from this list ! @ # $ % ^ & * ( ) _ + - = [ ] { } \ | ; :
‘“,.<>/?

*Confirm Password
Your passwords must match

Your password does not meet the requirements for passw
Please try again.
Your passwords do not match. Please try again.

* Security Question 1
What school did you attend for sixth grade?

* Security Answer 1

* Security Question 2
On what street was your first house?

* Security Answer 2

* Please type the text appearing in the image below:
Note: If you cannot view the image for any reason, please click on the speaker icon to hear the
code. Then enter the code in the box below.

Your entry does not match the image. Please try again.

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Website Registration * Indicates Required Field
* First Name

* Last Name

* Social Security Number

Suffix

* Date of Birth
MM/DD/YYYY

###-##-####

Address
Street

Post Office Box

Postal Type

Rural Route

* Box Number

Address Line 2
* City

* State

Phone Number (landline)

* Zip Code

Cell Phone Number

* County
E-Mail Address

YOU MUST ENTER A PHONE NUMBER ABOVE FOR THE AUTHENTICATION METHOD YOU
HAVE SELECTED!

*Create Your User Name (Must be at least 6 characters)
Your User Name does not meet the requirements for User
Name format. Please try again.
(Must be at least 8 characters and must contain at least three of the
*Create Your Password following items: one uppercase letter, one lower case letter, one number,
one special character from this list ! @ # $ % ^ & * ( ) _ + - = [ ] { } \ | ; :
‘“,.<>/?

*Confirm Password
Your passwords must match

Your password does not meet the requirements for passw
Please try again.
Your passwords do not match. Please try again.

* Security Question 1
What school did you attend for sixth grade?

* Security Answer 1

* Security Question 2
On what street was your first house?

* Security Answer 2

* Please type the text appearing in the image below:
Note: If you cannot view the image for any reason, please click on the speaker icon to hear the
code. Then enter the code in the box below.

Your entry does not match the image. Please try again.

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Website Registration * Indicates Required Field
If you are applying for a business, please register as an individual.

* First Name

* Last Name

Suffix

* Date of Birth

* Social Security Number

MM/DD/YYYY

###-##-####

Address
Street

Post Office Box

* Number

Rural Route

Box

Rural Route
Address Line 2
* City

* State

Phone Number (landline)

* Zip Code

Cell Phone Number

* County
E-Mail Address

YOU MUST ENTER A PHONE NUMBER ABOVE FOR THE AUTHENTICATION METHOD YOU
HAVE SELECTED!

*Confirm Password
Your passwords must match

Your password does not meet the requirements for passw
Please try again.
Your passwords do not match. Please try again.

* Security Question 1
What school did you attend for sixth grade?

* Security Answer 1

* Security Question 2
On what street was your first house?

* Security Answer 2

* Please type the text appearing in the image below:
Note: If you cannot view the image for any reason, please click on the speaker icon to hear the
code. Then enter the code in the box below.

Your entry does not match the image. Please try again.

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We cannot confirm your identity. Please contact our Customer Service
Center at (800) 659-2955 or (800) 877-8339 for people with speech or hearing
disabilities.

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Please enter your User Name and Password
Invalid User Name or Password. Please try again.
* User Name
* Password

Don't remember your Password?

After you have logged in, you may change your password or update your User Profile by
selecting the check boxes below .
Change Password

Update User Profile

You have logged in using a temporary password. Please create a new
password below. Remember, your new password must be at least 8
characters and must contain at least three of the following items: one
uppercase letter, one lower case letter, one number, one special character from
this list ! @ # $ % ^ & * ( ) _ + - = [ ] { } \ | ; : ‘ “ , . < > / ?
*Create New Password
Your password does not meet the requirements for
password format. Please try again.
*Confirm New Password
Your passwords do not match. Please try again.
Your passwords must match

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Please enter your User Name and Password
Invalid User Name or Password. Please try again.
* User Name
* Password

Don't remember your Password?

After you have logged in, you may change your password or update your User Profile by
selecting the check boxes below .
Change Password

Update User Profile

Your password has expired. Please create a new password below.
Remember, your new password must be at least 8 characters and must contain
at least three of the following items: one uppercase letter, one lower case letter,
one number, one special character from this list
!@ # $ % ^ & * ( ) _ + - = [ ] { } \ | ; : ‘ “ , . < > / ?
*Create New Password
Your password does not meet the requirements for
password format. Please try again.
*Confirm New Password
Your passwords do not match. Please try again.
Your passwords must match

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Please create your new password below. Remember, your new password
must be at least 8 characters and must contain at least three of the following
items: one uppercase letter, one lower case letter, one number, one special
character from this list
!@ # $ % ^ & * ( ) _ + - = [ ] { } \| ; : ‘“ ,. < > / ?
* Old Password
* New Password

Your passwords do not match.
Please try again.

* Confirm New Password

Reminder: Your new password will be valid for 90 days.

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User Profile
You may update any of the fields below except for your security question. When you have
completed your update, answer the security question then click the NEXT button.

Street

* Street #

Post Office Box

Rural Route

* Street Name

Suffix

* Street Type

Unit/Suite/Number

Address Line 2

City

Zip Code

State

Phone Number (landline)

Cell Phone Number

* County

E-Mail Address

Pass Code Delivery Method
Text message Delivery to Cell Phone
We will send a pass code to your cell phone. (Your cell phone must support SMS text messaging)
Voice Delivery to Home Phone
The system will call you on your landline telephone and read a pass code to you.
Voice Delivery to Cell Phone
The system will call you on your cell phone and read a pass code to you.

Secret Question

System randomly generated

* Secret Answer

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User Profile
You may update any of the fields below except for your security question. When you have
completed your update, answer the security question then click the NEXT button.

Street

Post Office Box

Postal Type

Rural Route

* Box Number

Address Line 2

City

Zip Code

State

Phone Number (landline)

Cell Phone Number

* County

E-Mail Address

Secret Question

System randomly generated

* Secret Answer

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User Profile
You may update any of the fields below except for your security question. When you have
completed your update, answer the security question then click the NEXT button.

Street

Post Office Box

* Number

Rural Route

Box

Rural Route
Address Line 2

City

Zip Code

State

Phone Number (landline)

Cell Phone Number

* County

E-Mail Address

Secret Question

System randomly generated

* Secret Answer

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If you do not remember your password please
answer the following question:
User Name
Secret Question
* Secret Answer

ENTER

E-Mail Address
Your password will be e-mailed to you once you click
the ENTER button.

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U.S. Small Business Administration
Electronic Disaster Loan Application

Federal Disaster Loans for Homeowners,
Renters, and Businesses of all Sizes
Apply for a Home /
Personal Property Loan

Apply for a Business /
Rental Property Loan

Continue An Existing
Application
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Select the application you would like to
complete
Select Reference Number

Loan Type

Applicant Name

Date Last Updated

1000000000

Home

Doe, John J

Last Update Date 1

1000000001

Business

Doe, Randy L

Last Update Date 2

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Home/Personal Property Losses
* Do you own or rent the address where your damages occurred?
Own
Rent
Other

* Was the address your primary residence at the time of the disaster?
Yes
No

It is a secondary home
Vacation homes or secondary homes, and their contents, are not eligible for SBA
disaster loans. However, if you rent them, they may be eligible as a rental property
(as defined by IRS) under the business disaster loan program.

It is a rental property
Rental properties are eligible for assistance as a Business application if the property
was rented prior to the disaster or was in the process of being rented. You will now be
directed to a business application.

Extended family members or other individual(s) are living there rent free
If a family member lived at the residence rent free prior to the disaster you, may be
eligible to apply for a loan.

What type of damage did you suffer? (check all that apply)
Real Estate
Personal Property (Clothing, Appliances, Furniture, etc.)
Auto

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You are requesting the following assistance
Real Estate
Personal Property (Clothing, Appliances, Furniture, etc.)
Auto

Is this correct?
Yes
No

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Enter your FEMA Registration Number, if you have one.
If you do not have a FEMA Registration Number please select
the state where the disaster occurred.
State

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We have not received your information from FEMA. You can continue
by selecting the state where the disaster occurred.
State

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The FEMA registration number you entered
is associated with the declaration listed
below.
State

California

County

Orange

* Is this correct?

Disaster Description

Tornado, Severe Storms

Disaster Date

05/20/2008

Yes
No

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Select the disaster that affected you
* County
State - State
* Active Disaster Declarations
Select Disaster Name

County where the damage occurred.
Disaster Description

Disaster Date

Disaster Name 1

Disaster Description 1

Incident Start Date 1

Disaster Name 2

Disaster Description 2

Incident Start Date 1

If you do not see the disaster that affected you, you may change the county where the
disaster damage occurred or please contact our Customer Service Center at (800) 659-2955
or (800) 877-8339 for people with speech or hearing disabilities.

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* STATEMENTS REQUIRED BY LAW AND
EXECUTIVE ORDERS

I accept
I do not accept

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I acknowledge that making materially false statements in this application is a crime
under federal law, punishable by fines of up to $250,000 and up to 30 years in prison,
under the following statues: 18 U.S.C. § 1040 (30 years), 18 U.S.C. § 1001 (5 years),
and 15 U.S.C. § 645 (2 years). I further acknowledge that if my loan is approved, at the
closing, I will be asked to sign a copy of this application certifying under penalty of
criminal prosecution that all information and documentation that I have provided is
truthful and accurate.

*I Acknowledge
Yes
No

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In this section we ask you about the applicant(s)
To complete this section, you will need the following information
• Social Security Number for you and for all co-applicants
• FEMA Registration Number, if available

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Please enter the following information about yourself
Same as Registrant

Prefix

*Indicates Required Field
MI *Last Name
*First Name

Suffix

*Social Security Number
Current Mailing Address
Street

* Street #

Post Office Box

* Street Name

Rural Route

* Street Type

Suffix

Unit/Suite/Number

Address Line 2
*City

*State

*Zip Code

* County

* Home Phone Number Alternate Phone Number E-Mail Address
FEMA Registration Number

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Please enter the following information about yourself
Prefix
*Indicates Required Field
MI

*First Name

*Last Name

Suffix

*Social Security Number
Current Mailing Address
Street

Post Office Box

Postal Type

Rural Route

* Box Number

Address Line 2
*City

*State

*Zip Code

* County

* Home Phone Number Alternate Phone Number E-Mail Address
FEMA Registration Number

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Please enter the following information about yourself
Prefix
*Indicates Required Field
MI

*First Name

*Last Name

Suffix

*Social Security Number
Current Mailing Address
Street

Post Office Box

* Number

Rural Route

Box

Rural Route
Address Line 2
*City

*State

*Zip Code

* County

* Home Phone Number Alternate Phone Number E-Mail Address
FEMA Registration Number

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Please tell us more about yourself
Date of Birth * (MM/DD/YYYY)

Closest relative not living with you
Name

* Marital Status

Phone Number

* Household Size (Including yourself)

* Do you own 20% or more of a corporation, partnership, limited partnership, or LLC?
Yes
No
* Business Name

City

* EIN

State

Type

Zip Code

% Owned

Add Another

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Applicant(s) Summary
Note: Only "Add" individuals of legal age whose information you would like to be considered during
the processing of this loan. If approved, this individual(s) will be a co-borrower(s) on the loan.

Primary Applicant
Doe, John J
Edit

Co-Applicant(s)
Doe, John J
Edit

Delete

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Please enter the following for the co-applicant
Relationship

Prefix

*First Name

Suffix

*Last Name

* Social Security Number
Same as Applicant

Current Mailing Address
Street

* Street #

Post Office Box

* Street Name

Rural Route

* Street Type

Suffix

Unit/Suite/Number

Address Line 2
* City

* State

Home Phone Number

Home 3245-0017

* Zip Code

* County

Alternate Phone Number E-Mail Address

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Please enter the following for the co-applicant
Relationship

Prefix

*First Name

Suffix

*Last Name

* Social Security Number
Same as Applicant

Current Mailing Address
Street

Post Office Box

Postal Type

Rural Route

* Box Number

Address Line 2
* City

* State

Home Phone Number

* Zip Code

* County

Alternate Phone Number E-Mail Address

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Please enter the following for the co-applicant
Relationship

Prefix

*First Name

Suffix

*Last Name

* Social Security Number
Same as Applicant

Current Mailing Address
Street

Post Office Box

* Number

Rural Route

Box

Rural Route
Address Line 2
* City

* State

Home Phone Number

* Zip Code

* County

Alternate Phone Number E-Mail Address

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Please tell us more about your co-applicant
Closest relative not living with you
Same as Applicant

Date of Birth * (MM/DD/YYYY)

Name

* Marital Status

Phone Number

Does this co-applicant own 20% or more of a corporation, partnership, limited partnership,
or LLC?
Yes
No
* Business Name

City

* EIN

State

Type

% Owned

Zip Code

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In this section we ask you about your damages and recoveries
To complete this section, you will need the following information
Copy of your deed, if available
Insurance policy (declaration page), if available
Claim settlement information, if available
If you do not have your insurance policy or settlement information, you may
be asked to provide the name, address and telephone number of your
insurance agent
For your protection, if you use a contractor, we urge you to consider one that
is bonded.

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Disaster Damaged Property Summary
Select "Add" next to the topic you want to visit to begin entering information regarding your disaster damaged property. You
may "Edit" your damaged property information but cannot delete, however, you may both "Edit" or "Delete insurance
information. When you are finished entering all of the information, select "Next" to continue. If you did suffer other damages,
you may add them to your application here. If you are unsure how to complete this screen, Please select help.

Real Estate
1923 Your Street, Dallas, TX 75248

(Primary Residence)

Add

Insurance
Allstate Insurance - Flood
Allstate Insurance - Homeowners

Edit

Personal Property

Edit

Add

1923 Your Street, Dallas, TX 75248

(Primary Residence)

Add

Insurance
Allstate Insurance - Homeowners
4453 Woodland Drive, Dallas, TX 75248

Add

Insurance
Allstate Insurance - Flood

Edit

Delete

Edit

Delete

Add

Auto

1923 Your Street, Dallas, TX 75248
Insurance

Add

Allstate Insurance - Flood

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 40 of 123

Was this address your primary residence at the time of the disaster?
Yes
No

Disaster Home loans for damaged real estate are available only for an owners’ primary residence.
Please click the Previous button to return to the Disaster Damaged Property Summary screen.

Please provide the address of the disaster
damaged real estate
Same as Mailing Address

* Street #

Street

* Street Name

Rural Route

* Street Type

Suffix

* Zip Code

* County

Unit/Suite/Number

Address Line 2
* City

* State

Please list the legal owner(s) of the disaster damaged
property
* Owner(s)

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 41 of 123

Was this address your primary residence at the time of the disaster?
Yes
No

Disaster Home loans for damaged real estate are available only for an owners’ primary residence.
Please click the Previous button to return to the Disaster Damaged Property Summary screen.

Please provide the address of the disaster
damaged real estate
Same as Mailing Address

Street

* Number

Rural Route

Box

Rural Route
Address Line 2
* City

* State

* Zip Code

* County

Please list the legal owner(s) of the disaster damaged
property
* Owner(s)

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 42 of 123

* Please estimate the cost to repair or replace
your disaster damaged real estate
$0 - $10,000
$10,001 - $100,000
Greater than $100,000
Unknown

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 43 of 123

Please provide details of the financial aid you received or expect to
receive from any other disaster relief agencies (FEMA, American Red
Cross, etc.) for your disaster damaged property
No Aid Received
Name of Agency

Amount Received/Expected

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 44 of 123

Select the type of insurance coverage in force for your disaster damaged
property
Flood

Homeowners/Other

None

If you are unsure, please check all that may apply.

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 45 of 123

Insurance Policy Information - Flood
* Insurance Company
Agent
Agent's Phone Number
Insurance Company Address
Street

* Street #

Post Office Box

* Street Name

* Street Type

Suffix

Unit/Suite/Number

Address Line 2
City

State

Zip Code

Policy Number
Claim Number (If any)
Real Estate
Policy Limit
Deductible
Settlement Amount

Pending

Amount Received

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 46 of 123

Insurance Policy Information - Flood
* Insurance Company
Agent
Agent's Phone Number
Insurance Company Address
Street

Post Office Box

Postal Type

Box Number

Address Line 2
City

State

Zip Code

Policy Number
Claim Number (If any)
Real Estate
Policy Limit
Deductible
Settlement Amount

Pending

Amount Received

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 47 of 123

Insurance Policy Information - Homeowners
* Insurance Company
Agent
Agent's Phone Number
Insurance Company Address
Street

* Street #

Post Office Box

* Street Name

* Street Type

Suffix

Unit/Suite/Number

Address Line 2
City

State

Zip Code

Policy Number
Claim Number (If any)
Real Estate
Policy Limit
Deductible
Settlement Amount

Pending

Amount Received

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 48 of 123

Insurance Policy Information - Homeowners
* Insurance Company
Agent
Agent's Phone Number
Insurance Company Address
Street

Post Office Box

Postal Type

Box Number

Address Line 2
City

State

Zip Code

Policy Number
Claim Number (If any)
Real Estate
Policy Limit
Deductible
Settlement Amount

Pending

Amount Received

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 49 of 123

At the time of the disaster, where was your
damaged personal property located?
Address 1
Other

Do you own or rent the address where your damages occurred?
Own
Rent
Street

* Street #

Rural Route

* Street Name

* Street Type

Suffix

Unit/Suite/Number

Address Line 2
* City

* State

* Zip Code

* County

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 50 of 123

At the time of the disaster, where was your
damaged personal property located?
Address 1
Other

Do you own or rent the address where your damages occurred?
Own
Rent
Street

Rural Route

* Number

Box

Rural Route
Address Line 2
* City

* State

* Zip Code

* County

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 51 of 123

At the time of the disaster, where was your damaged personal
property located?
Street

Same as Mailing Address

* Street #

* Street Name

Rural Route

* Street Type

Suffix

Unit/Suite/Number

Address Line 2
* City

* State

* Zip Code

* County

Do you own or rent the address where your damages occurred?
Own
Rent
Other

Was this address your primary residence at the time of the disaster?
Yes
No

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 52 of 123

At the time of the disaster, where was your damaged personal
property located?
Street

Same as Mailing Address

* Number

Rural Route

Box

Rural Route
Address Line 2
* City

* State

* Zip Code

* County

Do you own or rent the address where your damages occurred?
Own
Rent
Other

Was this address your primary residence at the time of the disaster?
Yes
No

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 53 of 123

Select the type of insurance in force for your
disaster damaged personal property
Same as Real Estate Damages

Flood

Homeowners/Other

None
If you are unsure, please check all that may apply.

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 54 of 123

Insurance Policy Information - Flood
* Insurance Company
Agent
Agent's Phone Number
Insurance Company Address
Street

* Street #

Post Office Box

* Street Name

* Street Type

Suffix

Unit/Suite/Number

Address Line 2
City

State

Zip Code

Policy Number
Claim Number (If any)
Contents
Policy Limit
Deductible
Settlement Amount

Pending

Amount Received

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 55 of 123

Insurance Policy Information - Flood
* Insurance Company
Agent
Agent's Phone Number
Insurance Company Address
Street

Post Office Box

Postal Type

Box Number

Address Line 2
City

State

Zip Code

Policy Number
Claim Number (If any)
Contents
Policy Limit
Deductible
Settlement Amount

Pending

Amount Received

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 56 of 123

Insurance Policy Information - Homeowners
* Insurance Company
Agent
Agent's Phone Number
Insurance Company Address
Street

* Street #

Post Office Box

* Street Name

* Street Type

Suffix

Unit/Suite/Number

Address Line 2
City

State

Zip Code

Policy Number
Claim Number (If any)
Contents
Policy Limit
Deductible
Settlement Amount

Pending

Amount Received

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 57 of 123

Insurance Policy Information - Homeowners
* Insurance Company
Agent
Agent's Phone Number
Insurance Company Address
Street

Post Office Box

Postal Type

Box Number

Address Line 2
City

State

Zip Code

Policy Number
Claim Number (If any)
Contents
Policy Limit
Deductible
Settlement Amount

Pending

Amount Received

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 58 of 123

Please provide the address where the auto was damaged
Address 1
Street

* Street #

Other (enter address below)

Rural Route

* Street Name

* Street Type

Suffix

Unit/Suite/Number

Address Line 2
* City

* State

* Zip Code

* County

Auto
* Make
* Model
* Year (YYYY)

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 59 of 123

Please provide the address where the auto was damaged
Address 1
Street

Other (enter address below)

Rural Route

* Number

Box

Rural Route
Address Line 2
* City

* State

* Zip Code

* County

Auto
* Make
* Model
* Year (YYYY)

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 60 of 123

Please provide the address where the auto was damaged
Street

* Street #

Rural Route

Same as Mailing Address

* Street Name

* Street Type

Suffix

Unit/Suite/Number

Address Line 2
* City

* State

* Zip Code

* County

Auto
* Make
* Model
* Year (YYYY)

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 61 of 123

Please provide the address where the auto was damaged
Street

Rural Route

Same as Mailing Address

* Number

Box

Rural Route
Address Line 2
* City

* State

* Zip Code

* County

Auto
* Make
* Model
* Year (YYYY)

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 62 of 123

* Did you have insurance coverage for your
disaster damaged year, make, model?

Yes
No

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 63 of 123

Insurance coverage for disaster damaged year, make, model
* Insurance Company
Agent

Agent's Phone Number

Insurance Company Address
Street

Post Office Box

* Street #

* Street Name

* Street Type

Suffix

Unit/Suite/Number

Address Line 2
City

State

Zip Code

Policy Number
Claim Number (If any)

Policy Limit (Auto)
Deductible
Settlement Amount
Pending
Amount Received

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 64 of 123

Insurance coverage for disaster damaged year, make, model
* Insurance Company
Agent

Agent's Phone Number

Insurance Company Address
Street

Post Office Box

Postal Type

Box Number

Address Line 2
City

State

Zip Code

Policy Number
Claim Number (If any)

Policy Limit (Auto)
Deductible
Settlement Amount
Pending
Amount Received

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 65 of 123

Note Regarding Insurance
SBA disaster loans are available for the amount of the disaster-related damages, LESS any
insurance recoveries and assistance from other disaster relief agencies.
It is not necessary that you settle with your insurance company before you apply for an SBA
disaster loan. If your claim is questioned or otherwise delayed, we can loan the full amount of
the damages so you can begin repairs. The insurance settlement is then assigned to us to
reduce the loan once the settlement is received.

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 66 of 123

In this section we ask you about your financial information
To complete this section, you will need the following information
Copies of your (and your spouse's, if you are married) most recently filed
Federal Income Tax Return, if available
If you have changed employment within the past 2 years, a copy of a current
(within 1 month of the application date) pay stub
If you are self-employed, current profit and loss statement and balance sheet,
if available
Mortgage holder’s name, address and telephone number
Your current bank statements, investment mortgage information, business and
farm records, stocks and bonds, and other investment records
Landlord’s name, address and telephone number
Creditors’ names (include all mortgages, credit cards, installment loans,
personal loans, vehicle loans), monthly payments and balances owed

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 67 of 123

Gross Income (Pre-Disaster)
Please check all sources of income for Applicant/Principal
Wages/Salary
Trust
Pension
Social Security/Disability
Interest/Dividends

Distributions From Retirement Accounts
Alimony
Child Support
Schedule C Business (income from individual business)
Schedule E Business (rents, royalties, K1 income)
Schedule F Business (farm or ranch income)

Other (Examples of OTHER income are regular part-time work, commissions, living
allowance, transportation allowance, and similar items.)

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 68 of 123

Wages/Salary

John Doe

*Employer's Name
Address
Street

* Street #

Post Office Box

* Street Name

* Street Type

Suffix

Unit/Suite/Number

Address Line 2
City

Zip Code

State

* Phone Number
Length of Employment * Years
* Title

* Months

* Occupation

* Supervisor's Name
* Gross Income
Previous

* Frequency

(pre-disaster)

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 69 of 123

Wages/Salary

John Doe

*Employer's Name
Address
Post Office Box

Street

Postal Type

Box Number

Address Line 2
City

Zip Code

State

* Phone Number
Length of Employment * Years
* Title

* Months

* Occupation

* Supervisor's Name
* Gross Income
Previous

* Frequency

(pre-disaster)

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 70 of 123

Other Income

John Doe
* Amount

* Frequency

Pension
Social Security/Disability
Interest / Dividends
Distributions From Retirement
Alimony
Child Support
Trust
Other - Description from
Financial - Income Sources

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 71 of 123

Schedule C Self Employment
Name of Business

John Doe

Business Trade Name

Type of Business

Business Annual Net Income
$

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 72 of 123

Schedule E Self Employment
Name of Business

John Doe

Business Trade Name

Type of Business

Business Annual Net Income
$

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 73 of 123

Schedule F Self Employment
Name of Business

John Doe

Business Trade Name

Type of Business

Business Annual Net Income
$

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 74 of 123

This screen will guide you to enter your income from all sources.
If you are unsure how to complete this screen, Please select help.

Smith, John J
Income Source

No Income

Enter Details

Wages - Wal-Mart - $25,000
Edit

Delete

Smith, Mary J
Income Source

No Income

Enter Details

Wages - Wal-Mart - $25,000
Edit

Delete

Johnson, Harry
Income Source

No Income

Enter Details

Wages - Wal-Mart - $25,000
Schedule E - ABC Corporation - less than$100,000
Edit

? Help

Delete

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 75 of 123

This screen will guide you through listing your assets and debts.
If you are unsure how to complete this screen, Please select help.

Note: If the applicant and co-applicant are spouses, please do not duplicate assets and debts.

Smith, John J
No Real Estate

Real Estate

Complete Details

4356 My Street, Dallas, TX 75248 - $250,000
Mortgage

Add

No Mortgage

Bank of America - $175,000
No Association
Association/Co-Op
Wood Park Association - $400

Add

No Personal Assets

Personal Assets

Personal Assets entered
No Extraordinary Expenses

Extraordinary Expenses

Add

Extraordinary Expenses entered
Add

No Debts

Debts

Debts entered

Leased Property

Add

No Leased Property

928 Your Street, Herndon, VA 20171
Landlord - John Smith

Smith, Robert R
Real Estate

Edit

Delete

Edit

Delete

Add

No Real Estate

4356 My Street, Dallas, TX 75248 - $250,000
Mortgage

Add

No Mortgage

Bank of America - $175,000
No Association
Association/Co-Op

Add

Wood Park Association - $400

Personal Assets

Add

No Personal Assets

Personal Assets entered
No Extraordinary Expenses
Extraordinary Expenses
Extraordinary Expenses entered

Add

No Debts

Debts

Add

Debts entered

Leased Property

Add

No Leased Property

10026 Your Street, Herndon, VA 20171
Landlord - John Smith

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 76 of 123

Real Estate
Address of disaster damaged property (dynamically generated)
Street

* Street #

Rural Route

* Street Name

* Street Type

Suffix

Unit/Suite/Number

Address Line 2
* City

* State

* Zip Code

* County

* Year Purchased
(YYYY)
* Purchase Price
* Current Resale Value (Pre - Disaster)
* Property Type

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 77 of 123

Real Estate
Address of disaster damaged property (dynamically generated)
Street

Rural Route

* Number

Box

Rural Route
Address Line 2
* City

* State

* Zip Code

* County

* Year Purchased
(YYYY)
* Purchase Price
* Current Resale Value (Pre - Disaster)
* Property Type

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 78 of 123

Association/Co-Op Contact Information
Name of Organization
Phone Number
Contact Name
* Association Fee

* Frequency

Association Address
Street

* Street #

Post Office Box

* Street Name

* Street Type

Suffix

Unit/Suite/Number

Address Line 2
City

State

Zip Code

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 79 of 123

Real Estate Mortgage
Address

* Name of Mortgage Holder
* Monthly Payment
* Balanced Owed
Is this a line of credit?
Yes

Maximum Credit Line
Are there any real estate taxes, insurance premiums included in your
monthly mortgage payment?
Yes

No
* Amount

* Frequency

Real Estate Taxes
Hazard Insurance
Previous

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 80 of 123

Please list other assets you own

If you are unsure how to complete this screen,

please select help.

Description

Total Amount

Cash and Bank Accounts (Include Certificates of Deposit but do
not include IRA's, Keogh's, or similar restricted retirement
accounts. Do Not include insurance proceeds.)
IRA's, Keogh's, and other similar restricted retirement accounts
Market value of stocks, bonds and other securities
Resale value of furnishings, household goods and appliances
Resale value of other assets (vehicle(s), boat, recreational vehicle, other assets)

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 81 of 123

Extraordinary Expenses
*Are you required to pay child care, child support or
alimony?
Yes (Indicate the amount per month)
No
*Do you pay tuition for schools required by medical disability, etc?
Yes (Indicate the amount per month)
No
*Do you pay unusually high and long-term medical costs?
Yes (Indicate the amount per month)
No
*Note: Include expenses that are expected to continue for 10 months
or more. DO NOT include normal living expenses.

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 82 of 123

Please provide information about your debts excluding
mortgages, rent, and extraordinary expenses.
Name of Creditor

Type of
Debt*

Payment
Frequency *
Amount *

Balance
Owed

How Secured

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 83 of 123

Rent/Lease Information
Street

* Street #

If you are unsure how to complete this screen, please select help.

Rural Route

* Street Name

* Street Type

Suffix

Unit/Suite/Number

Address Line 2
* City

* State

* Zip Code

* County

Landlord
* Name
Address
Phone Number
* Rent/Lease Amount

* Frequency

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 84 of 123

Rent/Lease Information
Street

If you are unsure how to complete this screen, please select help.

Rural Route

* Number

Box

Rural Route
Address Line 2
* City

* State

* Zip Code

* County

Landlord
* Name
Address
Phone Number
* Rent/Lease Amount

* Frequency

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 85 of 123

In this section we ask you other relevant questions
To complete this section, you will need the following information
Account information on existing direct or guaranteed Federal and SBA loans,
if available
Details on delinquent taxes, if available
Details on bankruptcies, if available
Details on any outstanding judgments and pending lawsuits, if available
Your alien registration or permanent residence card (if you are not a U.S.
citizen)

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 86 of 123

Hazard Mitigation
If your loan is approved, you may be eligible for additional funds to
cover the cost of safeguarding your property from similar damages as
caused by this disaster. It is not necessary for you to submit the
description and cost estimates with the application. SBA approval of
these safeguarding measures will be required before any loan increase.
By checking this box, you are interested in having SBA consider this
increase.
I am interested in Hazard Mitigation

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 87 of 123

If you answer yes to any of the questions, please provide the requested information.
Has the applicant/co-applicant ever had an SBA loan or an SBA guaranteed loan?
Yes
No
* Name(s)
SBA Office Location
Account Number
Has the applicant/co-applicant ever had any other Federal loan or a Federally guaranteed loan?
Yes

* Borrowers Name(s)
Agency Name

Office Location

Account Number
Previous

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 88 of 123

Is the applicant/co-applicant delinquent on any Federal taxes, direct or guaranteed loans (FHA,
VA, student, etc.), contracts, grants, or any child support payments?
Yes

* Debtor's Name(s)
Agency Name

Office Location

Account Number
Has the applicant/co-applicant ever been bankrupt?
Yes

No
Description/Current Status

* Debtor's Name(s)
Type of bankruptcy
Discharged?
Year Discharged
Previous

Yes

No
(YYYY)

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 89 of 123

Does the applicant/co-applicant have any judgments or lawsuits pending against them?
Yes
No
* Name(s)
(MM/DD/YYYY)

Date
Description

Has the applicant/co-applicant been convicted of a felony committed in connection with a riot or
civil disorder or ever 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
* Name

Description

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

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09/12/2008

Page 90 of 123

* Is the applicant/co-applicant currently suspended or debarred from contracting with the
Federal government or receiving Federal grants or loans?
Yes

Description

* Is the applicant/co-applicant currently, or have they ever been:
• under indictment, on parole or probation;
• 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
• 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

* Name

Description

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 91 of 123

Is the applicant/co-applicant an SBA employee?
Yes
No

Name

? Help

Exit

OMB Control No. 3245-0017 Exp. 12/31/2008

Home 3245-0017

09/12/2008

Page 92 of 123

Agreement and Certification
SBA has my permission, as required by the Privacy Act, to release
information to Federal, state, local or private disaster relief services
(American Red Cross, Salvation Army, Mennonite Disaster Services, etc.).
Yes
No

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Loan Representative Information
Did anyone other than an SBA representative assist you in completing this
application, whether you paid a fee for this service or not?
Yes
No

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Loan Representative Information
* Name

Company

Contact Phone Number
Current Mailing Address
Street

Street #

Post Office Box

Street Name

Street Type

Suffix

Unit/Suite/Number

Address Line 2
City

State

Zip Code

Fee Charged

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Loan Representative Information
* Name

Company

Contact Phone Number
Current Mailing Address
Street

Post Office Box

Postal Type

Box Number

Address Line 2
City

State

Zip Code

Fee Charged

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* Are you a U.S. citizen?
Yes
No

* Are you a Lawful Permanent resident alien?
Yes
No

* Provide alien registration number:

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NOTICE OF CRIMINAL PENALTIES FOR FALSE STATEMENTS AND MATERIAL OMISSIONS: Under Title 18
U.S.C. § 1040, any person who falsifies or conceals a material fact or makes a material misrepresentation in
connection with obtaining a disaster loan from or approved by the Small Business Administration can be subject to
criminal prosecution leading to imprisonment of up to 30 years and/or a fine of up to $250,000.
Read the following language carefully. Checking the box below indicates your agreement with the
following conditions and your certification as to the truthfulness of your application.
A. I authorize my insurance company, bank, financial institution, or other creditors to release to SBA all records
and information necessary to process this application.
B. 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.
C. 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.
D. 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.
CERTIFICATIONS: By checking the box below, I certify as follows:
(1) I have carefully reviewed each response to every question on this application and all supporting documents
provided in connection with my application, and that all responses and documents are true and complete to the best
of my knowledge.
(2) All financial statements submitted with this application fully and accurately present the financial position of the
business and I have not omitted any disclosures in these financial statements.
(3) I acknowledge that SBA is relying on this information in determining the eligibility of the applicant for an SBA
disaster loan, and that false statements or concealing material information may subject me to the criminal penalties
discussed above and/or forfeiture of benefits.
I Agree
If your loan is approved you will be required to sign this statement at loan closing.

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Please use this space for any additional information you wish to provide.
You cannot use the Enter Key or special characters

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The following item(s) are necessary to submit your application. You may enter them below, or
exit and return later to provide the information. If you choose to return later, you will be
returned to this page when selecting "Continue An Existing Application" after logging back
into the website.
Co-Applicants Name Social Security Number
Co-Applicants Name Date of Birth
Co-Applicants Name Mailing Address
Street

Post Office Box

* Street #

* Street Name

City *

Rural Route

State *

Same as Applicant

* Street Type
Zip Code *

Suffix

Unit/Suite/Number

County *

To assist you in gathering the information, you may print your list of
missing information by clicking the Print List button .
Previous

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XXX-XX-XXXX

Co-Applicants Name Date of Birth

MM/DD/YYYY

Co-Applicants Name Mailing Address
Street

Post Office Box

Postal Type *
City *

Rural Route

Same as Applicant

Box Number *
State *

Zip Code *

County *

To assist you in gathering the information, you may print your list of
missing information by clicking the Print List button .
Previous

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XXX-XX-XXXX

Co-Applicants Name Date of Birth

MM/DD/YYYY

Co-Applicants Name Mailing Address
Street

Post Office Box

Number *

Rural Route

Same as Applicant

Box

Rural Route
City *

State *

Zip Code *

County *

To assist you in gathering the information, you may print your list of
missing information by clicking the Print List button .
Previous

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John Doe

Ref# 1000000752

Before SBA can process your application, you must provide a completed Tax
Information Authorization (IRS Form 8821) for each applicant and co-applicant.
Tax Information Authorization (IRS Form 8821)
Applicant:
• Smith, John J
Co-Applicant(s):
• Smith, Hanna
• Smith, Mark

Click on a name to view the IRS Form 8821. Print and return the
signed IRS Form 8821 to SBA (You must include your 10 digit
reference # and full name) by:
E-m ail

E-mail your documents as an attachment to: [email protected]

Mail

Mail to:

Affiliate(s)
• Johns Barber shop,Inc

U.S. Small Business Administration
Processing & Disbursement Center
Attn: ELA Mail Department
P.O. Box 156119
Fort Worth, TX 76155

In-Person You can click on http://www.sba.gov for the location of a
center near you. If you cannot find a location, contact our
Customer Service Center @ (800) 659-2955, or (800) 8778339 for people w ith speech or hearing disabilities.

Also provide the following:
A current (within 1 month of the application date) pay stub for:
• Smith, Hanna

Print List

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Submit Application
To finish, click Submit.

Submit

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Do you need to enter another application?
Yes
No

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Notice:
You are being redirected from a secure site.
Do you want to proceed?

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You chose not to allow us to release information to other disaster relief
agencies or services. Other relief agencies or services rely on information
from the SBA to determine if you qualify for other assistance. You may not
receive some of the assistance for which you qualify. If you would like to
authorize the release of information, click Allow Release, otherwise click Next.
Allow Release

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You have said you do not accept our Terms of Use.
Please call our Customer Service Center at (800)
659-2955 or (800) 877-8339 for people with speech
or hearing disabilities, if you have questions about
our Terms of Use.

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We did not find any existing applications for you. If
this is incorrect, please contact our Customer
Service Center at (800) 659-2955 or (800) 8778339 for people with speech or hearing disabilities.

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“You have said you do not acknowledge. Please call
our Customer Service Center at (800) 659-2955 or
(800) 877-8339 for people with speech or hearing
disabilities, if you have questions”

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You have said you do not accept the Statements and
Executive Orders. Please call our Customer Service
Center at (800) 659-2955 or (800) 877-8339 for
people with speech or hearing disabilities, if you have
questions about the Statements and Executive
Orders.

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There are currently no active declarations for the
State and County combination you have selected.
Please contact Customer Service Center at (800)
659-2955 or (800) 877-8339 for people with speech
or hearing disabilities.

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You have exceeded the maximum number of
attempts. Your account is locked. Please contact
our Customer Service Center at (800) 659-2955 or
(800) 877-8339 for people with speech or hearing
disabilities.

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Please select at least one of the damage types.

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Notice:
You are being redirected to a secure
site. Do you want to proceed?

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Warning
You are not registered yet. If you leave now,
you will have to start the registration process
over.

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Warning
You are not registered yet. If you wish to
return, please visit our homepage to register
at www.sba.gov to start the registration
process over.

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Your information is saved.
You have not completed your information. To
complete your information, log back in.

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You must agree to continue. Please call our Customer Service Center at (800)
659-2955 or (800) 877-8339 for people with speech or hearing disabilities, if you
have questions. Click CANCEL to close message to check I Agree check box.
Click OK to exit and close browser.

CANCEL

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Your application has been submitted. Your
application will not be considered complete until you
submit the required supporting documentation. Your
Reference Number is 1XXXXXXXXX. Please write
it down for future reference.

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You have changed the delivery method or device used to
receive your validation code. You must login to verify
that your selection is working properly. If you are unable
to log back in, please call our Customer Service Center
at (800) 659-2955 or (800) 877-8339 for individuals with
speech or hearing disabilities.

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Your Registration is successful and complete.

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Do you wish to delete this information?

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File Type	application/pdf
File Title	document
Author	MLMOSELE
File Modified	2008-09-12
File Created	2008-09-11