SBA FORM 3504 EIDL Faith Based Entity Certification

U.S. SMALL BUSINESS ADMINISTRATION
ECONOMIC INJURY DISASTER LOAN SUPPORTING INFORMATION - FAITH BASED ENTITY
This information is to be submitted by Faith Based Entities in support of their application for an economic injury loan.
Eligibility for the loan is limited to those entities that provide eligible Secular Social Services on a nondiscriminatory
basis. A nondiscriminatory basis means that the services are available to the general public. Eligible Secular Social
Services include but are not limited to: (1) Child Care Services, (2) Housing and Shelter Services, and (3) Prepared and
Unprepared Food Distribution Services. Eligible expenses may include an amount for overhead expenses (such as rent,
utilities, mortgage interest) that are reasonably attributable to providing such services.
The estimated burden for completing this information is 30 minutes. You are not required to respond to this or any collection of
information unless it displays a currently valid OMB approval number. If you have any questions or comments concerning any
aspects of this information collection, please contact the U.S. Small Business Administration Information Branch, 409 3rd St.,
SW, Washington, DC 20416 and Desk Officer for SBA, Office of Management and Budget, Office of Information and Regulatory
Affairs, New Executive Office Building , Washington, DC 20503.

SBA Application Number (if known):

Name of Faith Based Entity:

Combined Annual Operating Expenses for all Secular Social Services provided by the Faith Based Entity:

$

List the Secular Social Services provided by the Faith Based Entity:

CERTIFICATION:

SBA Form 3504

I hereby certify under penalty of perjury that any proceeds of the EIDL loan or grant will only be used to
provide secular services on a nondiscriminatory basis, and that I have the authority to make this
certification, and that all of the foregoing is true and correct.

Signature and Title

SBA Form 3504

Date