SBA Form 700 Disaster Home Inquiry

D ISASTER HOME LOAN INQUIRY RECORD

PLEASE NOTE: The public reporting burden for this collection of information is estimated to average 15 minutes per response, including gathering and maintaining the data needed, and completing and reviewing the collection of information. You are not required to respond to any collection of information unless it displays a currently valid OMB Approval number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to: Chief, AIB, Room 5000, U.S. Small Business Administration, Washington, DC 20416; and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC 20503.

The Form 700 is used in non-Presidential declarations to document interviews with disaster survivors seeking a disaster loan application. It is also used in Presidential declarations to record interviews. SBA Form 700 is completed by ODA personnel based on the responses provided by the disaster survivors during the preliminary interviews. Signature of the prospective applicant is only used when interview results in a summary decline.

OMB No. 3245-0084

Expiration Date: XX/XX/XXXX

1. NAME OF PROSPECTIVE APPLICANT (if Inquirer is not applicant, state Inquirer’s

2. HOME TELEPHONE

relationship to “A” in comments section.)

last first mi

area code number

3. SSN OF PROSPECTIVE APPLICANT:

4. FEMA REGISTRATION NUMBER:

5. MAILING ADDRESS

EMAIL ADDRESS (optional):

number

street

city

county

state

zip

6. DAMAGED PROPERTY ADDRESS (If different from mailing address)

number street city county state zip

7. MARITAL STATUS OF PROSPECTIVE APPLICANT

8. SPOUSE’S NAME

married separated unmarried (single, divorced or widowed)

Will spouse be a joint applicant?

yes

no

9. DEPENDENTS

10. INSURANCE COVERAGE FOR THIS LOSS?

total number in family

 yes  no

11. GROSS INCOME

(NOTE: Alimony, child support or separate maintenance payments need not be disclosed if not a basis for repayment for this loan request.)

applicant gross salary $

week

OTHER income, gross (include joint applicant, if any) $

week

Source of OTHER income

month

month

year

year

12. DEBTS --- OTHER OBLIGATIONS: Include alimony, child support, real estate taxes and insurance, etc.

name and address of creditor

monthly pmt

name and address of creditor

monthly pmt

mortgage or rent

$

$

$

$

$

$

$

Total

$

13. SIGNATURE OF PROSPECTIVE APPLICANT

DATE

14. SIGNATURE OF PROSPECTIVE JOINT APPLICANT

DATE

15. TYPE OF INTERVIEW

Individual Group Telephone

18. SBA Use Only

16. APPLICATION GIVEN?

Yes on (date) _________ No, provide comments

17. COMMENTS

Recommending Official (sign & print name)

Concurring Official (sign & print name)

Form 1363 given on date ___________________

19. INTERVIEWER

signature

printed name

title

date

location

declaration number

SBA Form 700 Home (03-15) Ref. SOP 50-30 Previous Editions Obsolete