Form SBA Form 700 SBA Form 700 Disaster Home/Business Loan Inquiry Record

PLEASE NOTE: The public reporting burden for this collection of information is estimated to average 15 minutes per response, including gathering and maintaining the data needed, and completing and reviewing the collection of information. You are not required to respond to any collection of information unless it displays a currently valid OMB Approval number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to: Chief, AIB, Room 5000, U.S. Small Business Administration, Washington, DC 20416; and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC 20503.

U.S. Small Business Administration OMB No. 3245-0084

DISASTER HOME LOAN INQUIRY RECORD Expiration Date: 12/31/09

1. NAME OF PROSPECTIVE APPLICANT (if Inquirer is not applicant, state inquirer’s

2. HOME TELEPHONE

relationship to “A” in comments section.)

last first mi

area code number

3. SSN OF APPLICANT:

4. FEMA REGISTRATION NUMBER:

5. MAILING ADDRESS

number street city county state zip

6. DAMAGED PROPERTY ADDRESS (If different from mailing address)

number street city county state zip

7. MARITAL STATUS OF PROSPECTIVE APPLICANT

8. SPOUSE’S NAME

married separated unmarried (single, divorced or widowed)

Will spouse be a joint applicant?

yes

no

9. DEPENDENTS

10. INSURANCE COVERAGE FOR THIS LOSS?

total number in family

 yes  no

11. GROSS INCOME

(NOTE: Alimony, child support or separate maintenance payments need not be disclosed if not a basis for repayment for this loan request.)

applicant gross salary $

week

OTHER income, gross (include joint applicant, if any) $

week

Source of OTHER income

month

month

year

year

12. DEBTS ---OTHER OBLIGATIONS: Include alimony, child support, real estate taxes and insurance, etc.

name and address of creditor

monthly pmt

name and address of creditor

monthly pmt

mortgage or rent

$

$

$

$

$

$

$

Total

$

13. SIGNATURE OF APPLICANT

DATE

14. SIGNATURE OF JOINT APPLICANT

DATE

15. TYPE OF INTERVIEW

Individual Group Telephone

18. SBA Use Only

16. APPLICATION GIVEN?

Yes on (date) _________ No, provide comments

17. COMMENTS

Recommending Official (sign & print name)

Concurring Official (sign & print name)

Form 1363 given on date ___________________

19. INTERVIEWER

signature

printed name

title

date

location

declaration number

SBA Form 700 (12-06) Ref. SOP 50-30 Previous Editions Obsolete