Rapid Intake Form

4/30/2020

SBA - Disaster Loan Assistance

OMB Control #32450406
Expiration Date:
09/30/2020

Disaster Loan Assistance

Federal Disaster Loans for Businesses, Private Non-profits, Homeowners and Renters

COVID-19 ECONOMIC INJURY DISASTER LOAN APPLICATION

DISCLOSURES

BUSINESS INFORMATION

BUSINESS OWNERS INFORMATION

ADDITIONAL INFORMATION

SUMMARY

STREAMLINED PROCESS REQUIREMENTS
SBA is collecting the requested information in order to make a loan under SBA’s Economic Injury Disaster Loan Program to the qualified entities
listed in this application that are impacted by the Coronavirus (COVID-19). The information will be used in determining whether the applicant is
eligible for an economic injury loan. If you do not submit all the information requested, your loan cannot be fully processed.
The Applicant understands that the SBA is relying upon the self-certifications contained in this application to verify that the Applicant is
an eligible entity, and that the Applicant is providing this self-certification under penalty of perjury pursuant to 28 U.S.C. 1746 for verification
purposes.
The estimated time for completing this entire application is two hours and ten minutes, although you may not need to complete all parts. You are
not required to respond to this collection of information unless it displays a currently valid OMB approval number.

ELIGIBLE ENTITY VERIFICATION
Choose One:
Applicant is a business with not more than 500 employees.
Applicant is an agricultural enterprise 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 Employee Stock Ownership Plan (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 (but excluding all other
agricultural enterprises), with more than 500 employees that is small under SBA Size Standards found at https://www.sba.gov/size-standards
(https://www.sba.gov/size-standards).
Applicant is a business with more than 500 employees that is small under SBA Size Standards found at https://www.sba.gov/size-standards
(https://www.sba.gov/size-standards).
Applicant is a private non-profit organization that is a non-governmental agency or entity that currently has an e ective 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 nonrevenue producing organization or entity is a non-profit one organized or doing business under State law, or a faith-based organization.

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Review and Check All of the Following:
Applicant must review and check all the following (If Applicant is unable to check all of the following, Applicant is not an Eligible Entity):
Applicant is not engaged in any illegal activity (as defined by Federal guidelines).
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 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.

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Applicant does not derive more than one-third of gross annual revenue from legal gambling activities.
Applicant is not in the business of lobbying.
Applicant cannot be a state, local, or municipal government entity and cannot be a member of Congress.

If you have questions about this application or problems providing the required information, please contact our Customer Service Center at 1800-659-2955 or (TTY: 1-800-877-8339) [email protected].
Continue

SBA O ice of Disaster Assistance | 1-800-659-2955 | 409 3rd St, SW. Washington, DC 20416
Privacy Policy (https://www.sba.gov/about-sba/open-government/about-sbagov-website/privacy-policy)

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4/30/2020

SBA - Disaster Loan Assistance

OMB Control #32450406
Expiration Date:
09/30/2020

Disaster Loan Assistance

Federal Disaster Loans for Businesses, Private Non-profits, Homeowners and Renters

COVID-19 ECONOMIC INJURY DISASTER LOAN APPLICATION

DISCLOSURES

BUSINESS INFORMATION

BUSINESS OWNERS INFORMATION

ADDITIONAL INFORMATION

SUMMARY

Step 1 of 3

Business Information
Business Legal Name *

Trade Name *

EIN/SSN for Sole Proprietorship *

Organization Type*

Is the Applicant a Non-Profit Organization? *

Yes

No

Is the Applicant a Franchise? *

Yes

No

Gross Revenues for the Twelve(12) Month Prior to the Date of the Disaster (January 31, 2020) *

Cost of Goods Sold for the Twelve(12) Month Prior to the Date of the Disaster (January 31, 2020) *

Rental Properties (Residential and Commercial) Only - Lost Rents Due to the Disaster

Non-Profit or Agricultural Enterprise Cost of Operation for the Twelve(12) Month Prior to the Date of the Disaster (January 31, 2020)

Compensation From Other Sources Received as a Result of the Disaster

Provide Brief Description of Other Compensation Sources

Primary Business Address (Cannot be P.O. Box) *

City *
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State *

County

Zip *

Business Phone *

Alternative Business Phone

Business Fax

Business Email *

Date Business Established *

mm/dd/yyyy
Current Ownership Since *

mm/dd/yyyy
Business Activity *

Detailed Business Activity*

Number of Employees (As of January 31, 2020) *

Next

SBA O ice of Disaster Assistance | 1-800-659-2955 | 409 3rd St, SW. Washington, DC 20416
Privacy Policy (https://www.sba.gov/about-sba/open-government/about-sbagov-website/privacy-policy)

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4/30/2020

SBA - Disaster Loan Assistance

OMB Control #32450406
Expiration Date:
09/30/2020

Disaster Loan Assistance

Federal Disaster Loans for Businesses, Private Non-profits, Homeowners and Renters

COVID-19 ECONOMIC INJURY DISASTER LOAN APPLICATION

DISCLOSURES

BUSINESS INFORMATION

BUSINESS OWNERS INFORMATION

ADDITIONAL INFORMATION

SUMMARY

Step 2 of 3

Business Owners Information
Is Your Business Owned by a Business Entity? *

Yes

No

Business Applicant Parent Entity
Legal Name *

Street Address *

City *

State *

EIN *

ZIP *

Business Phone *

Business Email *

Business Type *

Ownership Percent *

If a Business Applicant is owned by a business entity, that business entity must provide information as part of this application and must sign a
guarantee.

Individual Owner(s)

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SBA - Disaster Loan Assistance

Complete for Each: a. Proprietor, or b. Limited partner or LLC member who owns 20% or more interest and each general partner or managing
member, or c. Stockholder or entity owning 20% or more voting stock.

Owner 1
First Name *

Last Name *

Mobile Phone *

Title / O ice *

Ownership Percent *

Email *

SSN *

Birth Date *

mm/dd/yyyy
Place Of Birth

U.S. Citizen *

Yes

No

Residential Street Address *

City *

State *

Zip *

Owner 2
First Name *

Last Name *

Mobile Phone *

Title / O ice *

Ownership Percent *
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Email *

SSN *

Birth Date *

mm/dd/yyyy
Place Of Birth

U.S. Citizen *

Yes

No

Residential Street Address *

City *

State *

Zip *

Remove Owner

Add Additional Owner

Back

Next

SBA O ice of Disaster Assistance | 1-800-659-2955 | 409 3rd St, SW. Washington, DC 20416
Privacy Policy (https://www.sba.gov/about-sba/open-government/about-sbagov-website/privacy-policy)

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4/30/2020

SBA - Disaster Loan Assistance

OMB Control #32450406
Expiration Date:
09/30/2020

Disaster Loan Assistance

Federal Disaster Loans for Businesses, Private Non-profits, Homeowners and Renters

COVID-19 ECONOMIC INJURY DISASTER LOAN APPLICATION

DISCLOSURES

BUSINESS INFORMATION

BUSINESS OWNERS INFORMATION

ADDITIONAL INFORMATION

SUMMARY

Step 3 of 3

Additional Information
In the past year, has the business or a listed owner been convicted of a felony committed during and in connection with a riot
or civil disorder or other declared disaster, or ever been engaged in the production or distribution of any product or service
that has been determined to be obscene by a court of competent jurisdiction?

Yes

No

Is the applicant or any listed owner currently suspended or debarred from contracting with the Federal government or
receiving Federal grants or loans?

Yes

No

a. Are you presently subject to an indictment, criminal information, arraignment, or other means by which formal criminal
charges are brought in any jurisdiction?

Yes

No

b. Within the last 5 years, for any felony, have you ever been convicted, plead guilty, plead nolo contendere, been placed on
pretrial diversion, or been placed on any form of parole or probation (including probation before judgment)?

If anyone assisted you in completing this application, whether you pay a fee for this service or not, that person must enter their
information below.
Individual Name

Name of Company

Phone Number

Street Address, City, State, Zip

Fee Charged or Agreed Upon

I give permission for SBA to discuss any portion of this application with the representative listed above.

Yes

No

Where to Send Funds

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SBA - Disaster Loan Assistance

Bank Name *

Account Number *

Routing Number *

On behalf of the individual owners identified in this application and for the business applying for the loan:
I/We authorize my/our insurance company, bank, financial institution, or other creditors to release to SBA all records and information necessary
to process this application and for the SBA to obtain credit information about the individuals completing this application.
If my/our loan is approved, additional information may be required prior to loan closing. I/We will be advised in writing what information will be
required to obtain my/our loan funds. I/We hereby authorize the SBA to verify my/our past and present employment information and salary
history as needed to process and service a disaster loan.
I/We authorize SBA, as required by the Privacy Act, to release any information collected in connection with this application to Federal, state, local,
tribal or nonprofit organizations (e.g. Red Cross Salvation Army, Mennonite Disaster Services, SBA Resource Partners) for the purpose of assisting
me with my/our SBA application, evaluating eligibility for additional assistance, or notifying me of the availability of such assistance.
I/We will not exclude from participating in or deny the benefits of, or otherwise subject to discrimination under any program or activity for which
I/we receive Federal financial assistance from SBA, any person on grounds of age, color, handicap, marital status, national origin, race, religion, or
sex.
I/We will report to the SBA O ice of the Inspector General, Washington, DC 20416, any Federal employee who o ers, in return for compensation of
any kind, to help get this loan approved. I/We have not paid anyone connected with the Federal government for help in getting this loan.
CERTIFICATION AS TO TRUTHFUL INFORMATION: By signing this application, you certify that all information in your application and submitted
with your application is true and correct to the best of your knowledge, and that you will submit truthful information in the future.
WARNING: Whoever wrongfully misapplies the proceeds of an SBA disaster loan shall be civilly liable to the Administrator in an amount equal to
one-and-one half times the original principal amount of the loan under 15 U.S.C. 636(b). In addition, any false statement or misrepresentation to
SBA may result in criminal, civil or administrative sanctions including, but not limited to: 1) fines and imprisonment, or both, under 15 U.S.C. 645,
18 U.S.C. 1001, 18 U.S.C. 1014, 18 U.S.C. 1040, 18 U.S.C. 3571, and any other applicable laws; 2) treble damages and civil penalties under the False
Claims Act, 31 U.S.C. 3729; 3) double damages and civil penalties under the Program Fraud Civil Remedies Act, 31 U.S.C. 3802; and 4) suspension
and/or debarment from all Federal procurement and non-procurement transactions. Statutory fines may increase if amended by the Federal Civil
Penalties Inflation Adjustment Act Improvements Act of 2015.
I hereby certify UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES that the above is true and correct.

Click for additional statements required by laws and executive orders
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SBA O ice of Disaster Assistance | 1-800-659-2955 | 409 3rd St, SW. Washington, DC 20416
Privacy Policy (https://www.sba.gov/about-sba/open-government/about-sbagov-website/privacy-policy)

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4/30/2020

SBA - Disaster Loan Assistance

OMB Control #32450406
Expiration Date:
09/30/2020

Disaster Loan Assistance

Federal Disaster Loans for Businesses, Private Non-profits, Homeowners and Renters

COVID-19 ECONOMIC INJURY DISASTER LOAN APPLICATION

DISCLOSURES

BUSINESS INFORMATION

BUSINESS OWNERS INFORMATION

ADDITIONAL INFORMATION

SUMMARY

Summary
Business Information
Edit
Business Legal Name
Main Street LLC
Trade Name
Main Street
EIN/SSN for Sole Proprietorship
Organization Type
Limited Liability Company
Is the Applicant a Non-Profit Organization?
No
Is the Applicant a Franchise?
No
Gross Revenues for the Twelve(12) Month Prior to the Date of the Disaster (January 31, 2020)
$650,000.00
Cost of Goods Sold for the Twelve(12) Month Prior to the Date of the Disaster (January 31, 2020)
$150,000.00
Rental Properties (Residential and Commercial) Only - Lost Rents Due to the Disaster
Non-Profit or Agricultural Enterprise Cost of Operation for the Twelve(12) Month Prior to the Date of the Disaster (January 31, 2020)
Compensation From Other Sources Received as a Result of the Disaster
Provide Brief Description of Other Compensation Sources
Primary Business Address (Cannot Be P.O. Box)
123 Main street
City
State
County
ZIP
Business Phone
Alternative Business Phone
Business Fax
Business Email

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SBA - Disaster Loan Assistance

Date Business Established
01/01/2000
Current Ownership Since
01/01/2001
Business Activity
Automotive Repair
Business Sub Activity
Automotive - Body Repair, Collision, Painting
Number of Employees (As of January 31, 2020)
350

Business Owners Information
Edit
Legal Name
Street Address
City
State
EIN
ZIP
Business Phone
Business Email
Business Type
Ownership Percent
5%

Owner 1
First Name
Last Name
Mobile Phone
Title / O ice
Owner
Email
Ownership Percent
90%
SSN
Birth Date
Place Of Birth
U.S. Citizen
No
Residential Street Address
City
State
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SBA - Disaster Loan Assistance

Zip

Owner 2
First Name
Last Name
Mobile Phone
Title / O ice
Email
Ownership Percent
5%
SSN
Birth Date
Place Of Birth
U.S. Citizen
Yes
Residential Street Address
City
State
Zip

Additional Information
Edit
In the past year, has the business or a listed owner been convicted of a felony committed during and in connection with a riot or civil disorder or other declared
disaster, or ever been engaged in the production or distribution of any product or service that has been determined to be obscene by a court of competent
jurisdiction?
No
Is the applicant or any listed owner currently suspended or debarred from contracting with the Federal government or receiving Federal grants or loans?
No
a. Are you presently subject to an indictment, criminal information, arraignment, or other means by which formal criminal charges are brought in any
jurisdiction? b. Within the last 5 years, for any felony, have you ever been convicted, plead guilty, plead nolo contendere, been placed on pretrial diversion, or
been placed on any form of parole or probation (including probation before judgment)?
No
Individual Name
Name of Company
Phone Number
Street Address, City, State, Zip
Fee Charged or Agreed Upon
I give permission for SBA to discuss any portion of this application with the representative listed above.
No

I'm not a robot
reCAPTCHA
Privacy - Terms

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SBA - Disaster Loan Assistance

SBA O ice of Disaster Assistance | 1-800-659-2955 | 409 3rd St, SW. Washington, DC 20416
Privacy Policy (https://www.sba.gov/about-sba/open-government/about-sbagov-website/privacy-policy)

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4/30/2020

SBA - Disaster Loan Assistance

OMB Control #32450406
Expiration Date:
09/30/2020

Disaster Loan Assistance

Federal Disaster Loans for Businesses, Private Non-profits, Homeowners and Renters

COVID-19 ECONOMIC INJURY DISASTER LOAN APPLICATION
Application Submitted
Your application number is

1328
You will not receive an email confirmation of your application submission. You will be notified through the email address
you submitted (EMAIL ADDRESS) when we are processing your application.
Please write down your application number or print this page for your records.

SBA O ice of Disaster Assistance | 1-800-659-2955 | 409 3rd St, SW. Washington, DC 20416
Privacy Policy (https://www.sba.gov/about-sba/open-government/about-sbagov-website/privacy-policy)
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