PLEASE NOTE: The estimated burden for completing this form is 15 minute per response

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DISASTER 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