Form SBA FORM 3503 SBA FORM 3503 Certification for EIDL Advance

U.S. SMALL BUSINESS ADMINISTRATION
SELF-CERTIFICATION FOR VERIFICATION OF ELIGIBLE ENTITY
FOR EMERGENCY EIDL ADVANCE
OMB Control Number 3245-XXX
Expiration Date:
You have applied for an SBA Economic Injury Disaster Loan (EIDL) that can be used for
working capital. By submitting this form, you are requesting that SBA provide an
advance on the EIDL loan while your application is being processed. SBA may provide
you with an EIDL advance of up to $10,000 for working capital. You will not be required
to repay this EIDL advance, even if your EIDL loan application is not approved. Loan
applicants seeking an advance on an economic injury loan must complete and submit
this form with the loan application or shortly thereafter.
If you also apply for and receive a loan through a lender under SBA’s Paycheck
Protection Program (PPP), the amount of loan forgiveness on the PPP loan for payroll
costs will be reduced by the amount of the EIDL advance.

Applicant Business Name:
Contact Person:
SBA Application Number (if known):
Federal E.I.N. (if applicable):
ACH Information:
Bank Name:
Routing Number:
SBA Form 3503

Account Number:

The Applicant listed above has applied for an SBA Economic Injury Disaster Loan (EIDL) in
response to the COVID-19 emergency.
The Applicant is requesting that SBA provide an advance on the EIDL loan in the maximum
amount available under the Coronavirus Aid, Relief, and Economic Security (CARES Act (up
to $10,000).
The Applicant understands that SBA is relying upon this self-certification to verify that the
Applicant is an eligible entity to receive the advance, and the Applicant is providing this
self-certification under penalty of perjury pursuant to 28 U.S.C. 1746 for verification
purposes.
ELIGIBLE ENTITY VERIFICATION
Choose One:
☐ Applicant is a business with not more than 500 employees
☐ Applicant is an individual who operates under a sole proprietorship, with or without
employees, or as an independent contractor
☐ Applicant is a cooperative with not more than 500 employees
☐ Applicant is an ESOP (as defined in 15 U.S.C. 632) with not more than 500 employees
☐ Applicant is a tribal small business concern, as described in 15 U.S.C. 657a(b)(2)(C),
with not more than 500 employees
☐ Applicant is a business, including an agricultural cooperative, aquaculture
enterprise, nursery, or producer cooperative, that is small under SBA Size
Standards located at https://www.sba.gov/document/support--table-size-standards/
☐ Applicant is a private non-profit organization that is a non-governmental agency or
entity that currently has an effective ruling letter from the IRS granting tax
exemption under sections 501(c),(d), or (e) of the Internal Revenue Code of 1954, or
satisfactory evidence from the State that the non-revenue producing organization
or entity is a non-profit one organized or doing business under State law, or a faithbased organization.
SBA Form 3503

Review and Check All of the Following:
Applicant must review and check all the following. If Applicant is not able to review and
check all the following, Applicant is not an Eligible Entity.
☐ Applicant is not engaged in any illegal activity
☐ No principal of the Applicant with a 50 percent or greater ownership interest is more
than sixty (60) days delinquent on child support obligations.
☐ Applicant is not an agricultural enterprise (e.g., farm), other than an aquaculture
enterprise, agricultural cooperative, or nursery.
☐ Applicant does not present live performances of a prurient sexual nature or derive
directly or indirectly more than de minimis gross revenue through the sale of
products or services, or the presentation of any depictions or displays, of a prurient
sexual nature
☐ Applicant does not derive more than one-third of gross annual revenue from legal
gambling activities
I CERTIFY UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES
THAT THE FOREGOING IS TRUE AND CORRECT.
Signature:

Date:

Name:
Title:
The estimated burden for completing this portion of the application is 10 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 Form 3503