Form SBA Form 2294 SBA Form 2294 Alternative Credit Worthiness Assessment

OMB Control Number 3245-0359
Expiration Date

SMALL BUSINESS ADMINISTRATION
Alternative Creditworthiness Assessment
Purpose for collecting the Information
Federal agencies are statutorily required to assess the creditworthiness of all new travel card applicants prior to issuing a card. See
e.g., Sec. 736 of the Consolidated Appropriations Act, 2012 (Pub. L. 112-74). Creditworthiness assessments are an important internal
control to ensure that credit cardholders are financially responsible. The information collected on this form is only required in the
circumstance when obtaining a credit score is not possible. The Small Business Administration (SBA) will use the information in
making a creditworthiness assessment to determine whether you possess a satisfactory credit history.
Providing Social Security numbers is purely voluntary. Social Security numbers are used to keep records accurate because other
people may have the same name and birth date. Executive Order 9397 also authorizes Federal agencies to use this number to help
identify individuals in agency records. Failure to furnish requested information, including your Social Security number, may delay or
prevent action on your application for employment.
Submitting the Form
Please submit the completed form to : the Human Resource office that requested the information.

Disclosure of Information
The collection, maintenance, and disclosure of credit information are governed by the Privacy Act. SBA will protect the information
you provide from unauthorized disclosure. If you are not offered employment this form will be destroyed at the end of the
employment selection process. However, if you become an employee of the Agency this form will become part of your personnel file
and will be maintained in a Privacy Act system of records. SBA has published notice in the Federal Register at 74 FR 14889 (April 1,
2009) describing the system of records in which your records will be maintained and the routine uses for information maintained in
the system of record; specifically SBA 31 Temporary Disaster Employee Files. You may obtain a copy of the notice from the SBA
personnel who requested that you complete this Form 2294, or from SBA’s website:
http://www.sba.gov/sites/default/files/Federal_Register_Revision_of_Privacy_Act_System_of_Records.pdf.
Please note that the information on this form and information that we collect during an assessment may be disclosed without your
consent as a routine use as permitted by the Privacy Act (5 USC 552a (b). Some of these routine uses include:
(1) To a Congressional office when the office is inquiring on the individual’s behalf;
(2)To SBA volunteers, interns, grantees, experts and contractors who have been engaged by the Agency to assist in the performance of
a service related to this system of records and who need access to the records in order to perform this activity.
(3) To the Department of Justice (DOJ) when any of the following is a party to litigation or has an interest in such litigation, and the
Agency determines the records are relevant and necessary to the litigation: (1) The Agency, or any of its components; (2) Any
employee of the Agency in his or her official capacity, or in an individual capacity where the DOJ has agreed to represent the
employee; or (3) The United States Government, where the Agency determines that litigation is likely to affect the Agency or any of
its components.
(4) In a proceeding before a court, or adjudicative body, or a dispute resolution body before which the Agency is authorized to appear
or before which any of the persons or entities listed above is a party to, or has an interest in the litigation; and the Agency determines
that such records are relevant and necessary to the litigation.
If you have questions or concerns regarding the disclosure of information or routine uses under the Privacy Act, you may contact the
Freedom of Information/Privacy Acts Office, 409 Third Street, SW, Washington, DC 20416 or [email protected].
Paperwork Reduction Act Disclosure Statement:
PLEASE NOTE: The estimated burden for completing this form is 15 minutes per response. You are not required to respond to any
collection of information unless it displays a current 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 (3245-0359). PLEASE DO NOT SEND FORMS TO OMB.
__________________________________________________
1. YOUR FINANCIAL RECORD

SBA Form 2294 (10-2016)

OMB Control Number 3245-0359
Expiration Date

In the last 7 years, have you filed a petition under any chapter of the bankruptcy code (to include Chapter 13)? Y
N
In the last 7 years, have you had your wages garnished for any reason?
Y
N
In the last 7 years, have you had any property repossessed for any reason?
Y
N
In the last 7 years, have you had a lien placed against your property for failing to pay taxes and other debts?
Y
N
In the last 7 years, have you had any judgments against you that have not been paid?
Y
N
If you answered “Yes” to any of the questions listed above, provide the information requested below:
Month/Year

Type of

Amount

Action

Name Action

Name/Address of Court or Agency

Occurred Under

Handling Case

State

ZIP Code

State

ZIP Code

YOUR FINANCIAL DELINQUENCIES
In the last 7 years, have you been over 180-days delinquent on any debt(s)?
Are you currently over 90 days delinquent on any debt(s)?

Y
Y

N
N

If you answered “yes” to either of the questions above, provide the information requested below:
Incurred
Month/Year

Satisfied
Month/Year

Amount

Type of Loan or
Obligation
and Account Number

Name/Address of Creditor or Obligee

PUBLIC RECORD CIVIL COURT ACTIONS
In the last 7 years, have you been a party to any public record civil court actions not listed elsewhere on this form?

Y

N

If you answered “yes”, provide the information about the public record civil court action requested below:
Month/
Year

Nature of
Action

Result of
Action

Name of Parties
Involved

Court (include City and
county/country if outside U.S.)

State

ZIP
Code

Certification That My Answers Are True
My statements on this form, and any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are
made in good faith. I understand that a knowing and willful false statement on this form can be punished by fine or imprisonment or
both. (See section 1001 of title 18, United States Code).

______________________________________________
PRINTED NAME

_________________________
SOCIAL SECURITY NUMBER

______________________________________________
SIGNATURE

________________________
DATE

SBA Form 2294 (10-2016)