SBA Form 0994R Application for Surety Bond Guarantee Assistance -Rider

OMB Control No. 3245-0007

Expiration Date 1/31/2010

U.S. Small Business Administration

Application for Surety Bond Guarantee Assistance – Rider

Under the American Recovery and Reinvestment Act of 2009

Directions: This form is to be completed by the small business for each bid and final guarantee application with an initial contract amount greater than $2 million. This form is to be completed in addition to the appropriate parts of SBA Form 994, and submitted to the surety agent or Preferred Surety Bond (PSB) surety of choice.

Does the contract involve the construction, renovation, or operation of a casino or other gambling establishment, golf course, zoo, aquarium, or swimming pool? □ yes □ no

Is the initial contract amount greater than $5 million?  yes  no

If yes, has the Contracting Officer issued a certification stating that the small business is experiencing difficulty obtaining a bond and that our SBA guarantee on the offer or contract is in the best interest of the Government?

 yes  no (Provide copy to your surety agent)

Contracting Officer’s Name:

Federal Agency Name:

Certification Date:

Offer Contract Number:

I certify that 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. 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.

Business Name: Business Trade Name

_________________________________________________________________________________

Principal’s Signature (Applicant) and Title

Date SBG Number

_________________________________________________________________________________

PLEASE NOTE: The estimated burden for completing this form is 1 minute 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., SW, Washington DC 20416 and Desk Officer for the Small Business Administration, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, DC 20503. OMB Approval (3245-0007) PLEASE DO NOT SEND FORMS TO OMB.

SBA Form 994 R (11-09) Previous Editions are Obsolete