SBA Form 994H Default Report Claim for Reimbursement

OMB No: 3245-0007

EXP. DATE: 01-31-2010

U.S. Small Business Administration

Surety Bond Guarantee Program

DEFAULT REPORT, CLAIM FOR REIMBURSEMENT,

AND RECORD OF ADMINISTRATIVE ACTION

Any intentionally false statement or willful misrepresentation in connection with a claim for payment pursuant to a Guarantee Agreement is a violation of Federal law, subject to criminal and civil prosecution under 18 USC Sections 287, 371, 1001, 15 USC Section 645 and 31 USC Section 3729 carrying possible fines and/or imprisonment.
GENERAL INSTRUCTIONS: This form combines SBA Forms 994H-Claim for Reimbursement, 994J-Report of Default, and 1101-SBA/SBG Modification/Administrative Action. It should be used as follows: (Please type or print legibly.) To file a Default Status Report; complete sections: A, B, C, H To file a Claim for Reimbursement; complete sections: A,C, E, F, G, H To record SBA Administrative Action; complete sections: A, C, D The surety company must print, sign, and mail to U.S. Small Business Administration, Office of Surety Guarantees, 409 3rd St., SW, Washington, DC, 20416
A. SBG IDENTIFICATION SUMMARY SBG NUMBER: ___________________________________________ SURETY ALPHA CODE: ___________________________________ BOND NUMBER: _________________________________________ CLAIM NUMBER: ________________________________________ DEFAULT STATUS CODE: BOND TYPE:  01=Active  02=Closed-No Loss  Payment  03=Closed-Subrogation  Performance  04=Closed-Final  Bid  05=Closed Settled DEFAULT REASON CODE: ________ (From reverse) SBA’s RESERVE AMOUNT: $ ___________________________	CONTRACTOR’S NAME: ______________________________________ _____________________________________________________________ 990 DATE: / / (See reverse) CONTRACT AMOUNT $__________ OBLIGEE: ___________________________________________________ PROJECT: ___________________________________________________ DEFAULT DATE: / / L AST STATUS REPORT: / / C LOSE DATE: (SBA USE ONLY) / / ____ NO CHANGE FROM PREVIOUS REPORT ____ STATUS UPDATE INCLUDED: (Describe below, current status and default completion plans.) SURETY RESERVE AMOUNT: $________________________________
B. SUBROGATION ACTIVITY (Explain in Section C., below, or attach a separate sheet if, necessary.) ____ Litigation pending ____ Settled for $_______________ ____ No change from last report ____ Payments being made ____ None – Bankrupt/Defunct ____ Approval requested to Close Final ____ Firm Collateral Held $_______________ Other anticipated recovery from salvage, indemnities, etc. $­­­­­______________________________________
C. EXPLANATIONS, COMMENTS, ADMINISTRATIVE ACTIONS (Attach additional sheet if warranted.)
(SBA USE ONLY) D. SBA/SBG CLAIM PAYMENT RECOMMENDATION, REVIEW, APPROVAL, AND AMOUNT OF CLAIM APPROVED THIS REQUEST IS HEREBY APPROVED FOR PAYMENT IN ACCORDANCE WITH SBA REGULATIONS. AMOUNT REQUESTED $________________ AMOUNT APPROVED $________________ EFFECTIVE DATE (Date SBA received) / /
RECOMMENDED BY REVIEWER 2ND REVIEWER APPROVING OFFICIAL (Signature/Title/Date) (Initials/Date) (Initials/Date) (Signature/Title/Date)

SBA Form 994H (11-09) REF. SOP 50-45 See instructions on reverse Page 1 of 3

5. ITEMIZATION OF SURETY LOSS (Loss Class Codes: L=Loss; E=Expense; TA=Trust Account Deposit)

List all loss items as well as funds deposited to a Trust Account. (See reverse)

DRAFT DRAFT LOSS

DATE NUMBER PAYEE AMOUNT CLASS

TOTAL $ _____________________________

5. ITEMIZED SURETY RECOVERY See Instructions. (Recovery Class Codes: I=Indemnity; C=Contract Funds)

DATE SOURCE RECOVERED RECOVERY

AMOUNT CLASS

TOTAL $ ______________________________

5. SUMMARY OF CLAIM FOR REIMBURSEMENT

Total of Loss Disbursements (Itemized Above) $ _____________________

Total of Loss Disbursements Previously Reported $ _____________________

TOTAL LOSS DISBURSEMENTS $ _____________________

Recovery (Itemized Above) $ _____________________

Recovery Previously Reported _____________________

Undisbursed Trust Account Balance (See reverse) _____________________

TOTAL OFFSETS $ ( ___________________ )

Surety Net Loss (Total Loss Disbursements Less Total Offsets) $ _____________________

Less Deductible Amount (See reverse) ( ____________________ )

SBA (_____ %) Share of Surety’s Reimbursable Loss ____________________

Less Prior Total SBA Payments ( ____________________ )

TOTAL DUE AND REQUESTED BY SURETY _____ OR TOTAL DUE AND SUBMITTED TO SBA _____ $ _____________________

H. CERTIFICATION

I, the undersigned being duly designated, hereby certify that this default report and/or itemization and summary of payments and recoveries received upon bonds issued in conjunction with the U.S. Small Business Administration’s Surety Bond Guarantee Program is true and correct to the best my knowledge, information and belief. I further certify that all payments made and recoveries received are substantiated by payroll sheets, copies of Surety’s drafts, claimants invoices, assignments and releases (where applicable), recovery instruments, etc., and that such substantiating documents are retained in this office, our agent’s office, or in the office of our claim account trustee. I further certify that the Surety has complied with all SBA Surety Bond Guarantee Program regulations in 13 CFR Part 115 and all SBA program requirements.

NAME OF SURETY (Area Code/Phone No.) SURETY CERTIFYING OFFICIAL’S SIGNATURE, TITLE, AND DATE

SBA Form 994H (11-09) REF. SOP 50-45 See instructions on reverse Page 2 of 3

INSTRUCTIONS AND CLARIFICATION

OF SELECTED FORM 994H ITEMS

General

1. This form may be used to report the default of an SBG contractor, as well as for periodic status reporting in accordance with the terms of SBA’s Surety Bond Guarantee Agreement. If a different format is used, all information requested on 994H Form must be provided.

2. A separate SBA Form 994H must be used for each bond in default/claim status. An additional sheet/letter may be attached for more detailed reporting.

3. If this is an initial default/claim notice:

   1. A carbon copy of this form should be sent simultaneously to the SBA Field Office which guaranteed the bond in caption.

   2. Provide a detailed report including the percentage of completion, remaining contract funds, methods of selecting completion contractor, description of how claim situation arose, present condition, surety’s plans for resolution and salvage, anticipated loss.

Specific
Section A.	“SBG Number” – enter the full 14-digit number. “990 Date” is the date SBA Form 990, “Surety Bond Guarantee Agreement,” was signed by SBA Official. DEFAULT REASON CODES:
	CODE Underbidding Weather/natural disasters Shortage in critical materials/ Delays in receiving same Alleged embezzlement Financial mismanagement Incompetence/poor workmanship Union strike/labor trouble Illness or death of key employee Walked off job Dispute with obligee Possible fraudulent operation on part of principal Despondency Co-mingling of funds	CODE General’s subcontractor in default Sub’s General in default Possible sub-busting on part of general IRS lien Sub’s General behind Schedule Unforeseen physical obstacle Shortage of labor Principal fails to appear at job site to begin work Fire damage Materialman lien Labor lien Principal failed to sign contract Surety did not issue final bond Other
Section E.	List all loss items as well as funds deposited to a trust account. A separate accounting must accompany any request for reimbursement of loss incurred via a trust account. Such accounting must provide the source of all deposits to the account, and the disposition of all funds from the account (by date, draft number, payee and amount). Any balance remaining in the account or any amounts not accounted for as expenditures comprise the trust account balance and are to be included in Section G. as “Undisbursed Trust Account Balance.”
Section F.	List all recovery items received by the Surety. Also, list as recovery, all trust account remaining balances returned by the trustee.
Section G.	The “Undisbursed Trust Account Balance” is reduced to zero when the remaining balances are returned by the trustee. See instructions for Section E., above. The “Total of Loss Disbursements” is the total amount from Section E., “Itemization of Surety Loss.” The “TOTAL LOSS DISBURSEMENTS” is the combined total of loss disbursements itemized and previously reported. The “Deductible Amount” is 80% of the Premium amount up to $500 for Guarantee Agreements written on/after April 21, 1976.

PLEASE NOTE: The estimated burden for completing this form is 20 minutes 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 994H (11-09) REF, SOP 50 45 Page 3 of 3