SBA FORM 2136 PART Lender's Supplemental Information America's Recovery Cap

OMB Control No: 3245-0366 Expiration Date: 12/31/2009

Expiration Date: 12/31/2009

MB Approval No.: 3245-0348

Effective Date: 02/19/2004

Expiration Date: 02/28/2007

LENDER’S Supplemental Information for

America’s Recovery Capital (ARC) Loan Guaranty Request

Borrower Name:

Trade Name (dba):

(if no trade name, enter “NA”)

Borrower Contact:

Mr

Ms

First

MI

Last

Borrower Street:

Borrower Zip Code:

Borrower Phone #:

Borrower SSN #:

(must include SSN # for principal of borrower)

#

Employer ID #:

(if available)

Borrower State:

(2 letter abbreviation)

Borrower County:

Borrower City:

Lender Name:

Lender ID #:

Loan Maturity:

(in months)

Loan Amount:

$

SBA Guaranty %:

%

Applicant’s Duns #:

Exporter?

Yes

No

New Business
Outstanding SBA Loan

Rural

or

Urban

NAICS Code:

Number of Employees:

Number of Jobs Created:

Number of Jobs Retained:

Franchise?

Franchiser’s Name:

SBA USE ONLY:

Sole Proprietorship?

Partnership?

Corporation?

Other?

Veteran*		1=Non-Veteran; 2=Veteran-Other; 3=Service-Disabled Veteran; 4=Not Disclosed.
Gender*		M=Male; F=Female; N=Not Disclosed
Race*		1=American Indian or Alaska Native; 2=Asian; 3=Black or African-American; 4=Native Hawaiian or Pacific Islander; 5=White; X=Not Disclosed
Ethnicity*		H=Hispanic or Latino; N=Not Hispanic or Latino; Y=Not Disclosed
Owner #	% Owned		Veteran	Gender	Race	Ethnicity	Please reference the above to complete this table for each 20% or greater owner of the primary business associated with the borrower. Each block must be completed. More than one race may be selected.

* The gender/race/ethnicity/veteran data is collected for statistical purposes only. Disclosure is voluntary and has no bearing on the credit decision.

Borrower Name:

Use of Loan Proceeds - Payment of Qualifying Small Business Loans	Amount (P&I)
Pay Notes Payable – Trade, etc.*	$
Pay Notes Payable – Mortgage - not Same Institution Debt (SID)	$
Pay Notes Payable – Mortgage - Same Institution Debt (SID)	$
Pay Notes Payable – Secured Lender Debt - not SID	$
Pay Notes Payable – Secured Lender Debt - SID	$
Pay Notes Payable – Unsecured Lender Debt (except credit card debt) - not SID	$
Pay Notes Payable – Unsecured Lender Debt (except credit card debt) - SID	$
Pay Capital Lease	$
Pay SBA Loan made on or after 2/17/09	$
Pay Credit Card Debt	$
Pay Home Equity Loan	$
Total	$

*Notes to vendors, trade, utilities, or other services that are for past due amounts that were converted to a note payable (with or without interest).

Please check all that apply below. You must choose at least one. (Must be completed):

The small business applicant requires an ARC loan due to the following adverse financial condition(s) resulting in immediate financial hardship:

 Loss/Reduction of customer base (or loss/reduction of revenue of 20% or more over the preceding 12 months)

 Increase in cost of doing business of 20% or more over the preceding 12 months

 20% or more loss/reduction of Working Capital and/or loss/reduction of short term Credit Facilities over

preceding 12 months

 Decline in Gross Margin of 20% or more over the preceding 12 months

 Decline in Operating Ratios of 20% or more over the preceding 12 months

 Inability to restructure existing debts due to credit restrictions within the preceding 12 months

 Loss/Reduction of Employees

 Loss/Reduction of Major Suppliers (major suppliers out of business)

Other Immediate Financial Hardship – Explain:____________________________________________________

Lender Contact:

Mr

Ms

First

MI

Last

Lender Contact Phone #:

Lender Contact Fax #:

NOTE: According to the Paperwork Reduction Act, you are not required to respond to this collection of information unless it displays a currently valid OMB Control Number. The estimated burden for completing this form, including time for reviewing instructions, gathering data needed, and completing and reviewing the form is 15 minutes per response. Comments or questions on the burden estimates should be sent to U.S. Small Business Administration, Chief, AIB, 409 3rd St., SW, Washington DC 20416. PLEASE DO NOT SEND FORMS TO THIS ADDRESS.

SBA Form 2316 (Part B) (___) 2