Form SBA Form 1366 SBA Form 1366 Borrower's Program Certification

O MB Approval No. 3245-0110

Expiration Date: XX-XX-XX

SBA DISASTER ASSISTANCE PROGRAM

SBA FORM 1366

BORROWER'S PROGRESS CERTIFICATION

1. This form is to be used by SBA’s disaster loan borrowers to account for expenditures to repair or replace your disaster damaged property. Use this form when you are ready to request a subsequent disbursement.

2. Under “Accounting of Loan Funds Spent” list how you spent the last disbursement. Attach photocopies of receipts, for items exceeding $1,000.00, as instructed.

3. Under “Listing of Definite Commitments” list items you have purchased or contracted for but have not yet paid. Attach copies of the invoices or contracts as instructed.

4. Attach a short note requesting a subsequent disbursement. Explain how much you need, when you need it and what it will be used for.

4. By signing this form, you will certify, among other things, that:

• the funds from this loan have been and will be used in accordance with the Use of Loan Proceeds and Compensation from Other Sources paragraph of the Loan Authorization and Agreement,

• that there has been no adverse change in your financial conditions since application,

• that you have used all additional funds from other sources,

• that you have not received or requested additional funds from other sources without making SBA aware, and

• that you will return any unused loan funds to SBA.

Privacy Act (5 U.S.C. § 552a)

SBA collects this information to verify use of loan proceeds and so that borrowers may provide certifications that are required before additional funds can be disbursed.. Disclosures of name and other personal identifiers are required for a benefit, as SBA requires an individual seeking assistance from SBA to provide it with sufficient information for it to make an eligibility and credit decision. In making loans pursuant to Section 7(b) of the Small Business Act, SBA is required to have reasonable assurance that the loan is of sound value and will be repaid or that it is in the best interest of the Government to grant the assistance requested. For these purposes, you are asked to provide your name and loan number so that SBA can assure itself that loan proceeds are being properly used and determine whether additional funds can be disbursed.

Any person can request to see or get copies of any personal information that SBA has in its files. Information that is retrieved by individual identifiers, such as name or social security number is protected under the Privacy Act (PA) and maintained by SBA in PA System of Record, SBA 20 – Disaster Loan Case Files. Requests for information about another party that is maintained in such a system may be denied unless SBA has the written permission of the individual to release the information to the requestor; or unless the information is subject to disclosure under the Freedom of Information Act, or one or more of the routine uses listed in SBA System of Record - 20 .

U.S. SMALL BUSINESS ADMINISTRATION

BORROWER’S PROGRESS CERTIFICATION

Name	App. No. / Loan No. DLH

DOCUMENTATION OF 100% OF OUTSIDE FUNDS (INCLUDING BUT NOT LIMITED TO GRANT FUNDS, INSURANCE FUNDS, FEMA REPAIR FUNDS, FUNDS FOR ANY ELECTIVE UPGRADING, PERSONAL FUNDS REQUIRED TO COMPLETE THE PROJECT, FUNDS FROM CIVIL LIABILITY CLAIMS, SALVAGE) MUST BE SUBMITTED TO THE SBA BEFORE ADDITIONAL FUNDS OVER THE INITIAL SBA DISBURSEMENT CAN BE RECOMMENDED.

AFTER 100% OF THE OUTSIDE FUNDS ARE INJECTED INTO THE REPAIR PROJECT AND 80% OF THE SBA FUNDS DISBURSED TO DATE HAVE BEEN ACCOUNTED FOR, ADDITIONAL SBA FUNDS CAN BE REQUESTED.

For the purpose of receiving additional funds from my loan, I/we certify, except as noted below, that:

* The listing on the reverse side is a true and accurate listing of the use of the loan funds I/we have received to date;

* The funds from this loan have been and will be used in accordance with the “Requirements for Use of Loan Proceeds” and the “Agreement to Remit and Assignment of Compensation from Other Sources” paragraphs of the Loan Authorization and Agreement;

* There has been no adverse change in my/our financial condition since the date of the loan application. (Adverse changes include but are not limited to: judgment liens, tax liens, mechanics’ liens, bankruptcy, financial reverses, etc.);

* If the borrower is a business entity, there has been no change in the form of organization since such date;

* No fees have been paid or agreed to be paid to a representative (attorney, accountant, etc.) for assistance in connection with this loan except as previously reported on the application or SBA Form 159(D), “Compensation Agreement”;

* Prior to disbursement of further SBA Loan funds for real estate construction or repair, I/we have provided evidence satisfactory to SBA that all outside funds received for disaster damages to the real estate, and any other funds necessary to complete the repair/ replacement project, have been spent for the repair or replacement of the disaster damaged real estate ; and

* I/we will return to SBA, as soon as possible but not later than 1 year from the date of final disbursement, all funds received but not used for disaster repairs.

Describe any exceptions to the above statements here (attach an additional sheet if necessary):

CERTIFICATION:

I hereby certify that (1) I have reviewed all of the certifications above and all certifications are true and correct; (2) I have reviewed all of the responses to the questions in this form and all exhibits and attachments submitted with this form, and (3) all information, exhibits, and attachments are true and correct to the best of my knowledge. I understand that the U.S. Small Business Administration is relying on this information in order to decide whether to make additional disbursements on my loan.

CRIMINAL AND OTHER PENALTIES FOR FALSE STATEMENTS:

Any intentional or negligent misrepresentation of the information contained in this form may result in criminal, civil or administrative sanctions including, but not limited to: 1) fines of up to $500,000, and imprisonment of up to 10 years, or both, as set forth in 15 U.S.C. § 645 and 18 U.S.C. § 1001, as well as any other applicable criminal laws; 2) treble damages and civil penalties under the False Claims Act; 3) double damages and civil penalties under the Program Fraud Civil Remedies Act; and 4) suspension and/or debarment from all Federal procurement and nonprocurement transactions.

Borrower’s signature

Date

PLEASE NOTE. The estimated burden for completing this form is 30 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., S.W., Washington D.C. 20416 and Desk Officer for the Small Business Administration, Office of Management and Budget, New Executive Office Building, Room 10202, Washington D.C. 20503.

SBA use only

SBA Form 1366 (10-09) SOP 50-30 All previous editions obsolete

ACCOUNTING OF LOAN FUNDS SPENT

List all funds spent to repair or replace disaster-damaged property as follows:

1. Please provide a copy of each individual invoice/receipt over $1,000, enter it on a separate line below and indicate on the invoice/receipt how it was paid (check #, credit card, cash, etc.) or copies of cancelled checks, and/or paid receipts, etc. Photocopies are acceptable.

2. Any invoices/receipts less than $1,000 may be grouped together and entered on a separate line – do not submit these individual receipts. For example, multiple receipts totaling $850 for personal property can be grouped together or multiple receipts totaling $1,500 for building materials can be grouped together, etc.)

3. After 100% of the outside funds are injected into the repair project and 80% of the SBA funds disbursed to date have been spent, additional SBA funds can be requested.

Item (or group of items) purchased/work performed	Amount $
TOTAL	$

LISTING OF DEFINITE COMMITMENTS (not yet paid) FOR REPAIRS AND REPLACEMENTS

Use the same groupings as described above. (Attach copies of Bids/Estimates, Construction Material Purchase Orders, Contracts, etc., for each item that you estimate will cost $1,000 or more,.)

Description of item(s) committed and/or contracted	Amount $
TOTAL	$

If you need additional space above, please make copies of this second page.

YOU MUST SIGN AND DATE PAGE 1 OF THIS FORM.

REMINDER: Although they do not have to be submitted now, you must obtain and keep records, receipts, cancelled checks, etc., for all purchases or work performed, regardless of cost, for 3 years from the date of the last check you receive on your loan. SBA may require you to show those records at any time from now until the end of the 3-year period.

We suggest you keep a copy of this form for your records.