Form SBA Form 700 Home SBA Form 700 Home Disaster Business Loan Inquiry Record

DISASTER HOME LOAN INQUIRY RECORD
PLEASE NOTE: You are not required to respond to any request for information unless it displays a currently valid OMB Approval number. The estimated time to respond to this form,
including gathering the data is 15 minutes. You may send comments or questions regarding this time or other aspect of this form to: Director, Records management Division, 409 Third
Street, 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 DC 20503.
PURPOSE: Your responses to the questions on this form will help SBA’s Office of Disaster Assistance to make a preliminary determination regarding your eligibility for an SBA disaster
loan. SBA may also report the information to the Federal Emergency Management Agency (FEMA) to facilitate your receiving assistance from that agency. The information requested
includes your social security number. At this preliminary stage, providing your social security number is voluntary; however, Executive Order 9397, as amended, allows SBA to collect the
number to help distinguish you from others with the same or similar name who may have also applied for assistance from SBA and/or FEMA. SBA will protect your personal information to
the extent permitted by law, including the Privacy Act and the Freedom of Information Act, and SBA’s Privacy Act System of Records, SBA 20–Disaster Loan Case Files.

OMB No. 3245-0084
Expiration Date: xx/xx/xxxx

1. NAME OF PROSPECTIVE APPLICANT

2a. PHONE - HOME:

(if Inquirer is not applicant, state Inquirer’s relationship to “A” in comments section.)
last
first
mi

2b. PHONE - CELL:

3. PROSPECTIVE APPLICANT
SSN:
DOB:

4. FEMA REGISTRATION NUMBER:
EMAIL ADDRESS :

5. MAILING ADDRESS
number

street

city

county

zip

state

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

street

city

unmarried (single, divorced or widowed)

zip

Joint Applicant SSN:
Joint applicant DOB:

10. INSURANCE COVERAGE FOR THIS LOSS?

9. HOUSEHOLD SIZE:
11. INCOME

state

8. JOINT APPLICANTS NAME:

7. MARITAL STATUS:
married

county

yes

no

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

Applicant total annual income: $

Joint Applicant total annual income: $

12. DEBTS --- OTHER OBLIGATIONS: Include alimony, child support, real estate taxes and insurance, etc.
Name and address of creditors
Mortgage or Rent

monthly pmt

Name and address of creditors

monthly pmt

$

$

$

$

$

$
Total

$

$

13. PAPER APPLICATION ISSUED?
Yes on (date)

No, provide comments

Form 1363 given on:

14. COMMENTS

15. INTERVIEWER
signature

printed name

location
SBA Form 700 Home (xx-xx) Ref. SOP 50-30

title

declaration number
Previous Editions Obsolete

date