Form SBA Form 3513 SBA Form 3513 EIDL Declaration of Identity Theft

OMB Control Number 3245-XXXX

Expiration Date: xx/xx/xxxx

United States Small Business Administration

Declaration of Identity Theft

Complete this form if you need the U.S. Small Business Administration to review an outstanding loan or grant for identity theft. Before beginning, please note that a hand-written signature is required for this declaration, as well as attachments.

Providing the information on this form is voluntary. However, if you do not provide the information it may be more difficult to assist you in resolving your identity theft issue. Send completed forms via email to: [email protected].

Section A – Check the box below that applies to the situation you are reporting

☐ I am submitting this Declaration for myself as a sole proprietor/individual or as the authorized representative for a business named ________________________________.¹

☐ I am submitting this Declaration on behalf of my minor child (or I am the guardian of the minor child).²

☐ The identity theft victim is deceased, and I am submitting this Declaration as the surviving spouse, Court-Appointed Personal Representative, Executor, or Administrator.³

☐ The identity theft victim is incapacitated, and I am submitting this Declaration as the Power of Attorney, Court-Appointed Guardian, or Conservator.⁴

Section B – Representative, Conservator, Parent or Guardian contact information⁵

Representative’s Last Name: __________________________First Name: ____________________

Current Street Mailing Address: _____________________________________________________

City: _______________________ State: _____ ZIP Code: ______________

Telephone Number: ______________________Alternate Telephone Number: ________________

Email address: _________________________________________________________________

Section C – Name and contact information of Identity Theft Victim

Victim’s Last Name: _____________________________First Name: _______________________

Social Security Number (Please provide 9-digit Social Security Number): ____________________

Current Street Mailing Address: ___________________________________________________

City: ____________________ State: _____ ZIP Code: ______________

Telephone Number: ____________________Alternate Telephone Number: __________________

Email address: _________________________________________________________________

Complete if applicable:

Victim’s Business Name: ________________________________________________________

Business Owner(s) Name(s): ______________________________________________________

Taxpayer Identification Number (EIN or TIN): _______________________________________

Business Street Mailing Address: __________________________________________________

City: ____________________ State: __ ZIP Code: __________

Section D – Declaration

Please carefully review the information you have provided in this form. Then review the statement provided below and, if appropriate, sign and date in the fields provided. Please remember you must sign this declaration by hand. Electronic signatures will not be accepted.

I, _____________________________, residing at _____________________________________ hereby declare under penalty of perjury as follows:

Please check and complete as appropriate:

☐ On or about __________, I allege that someone used my personal identifying information (PII) or the identifying information of my business without my permission or knowledge to obtain a loan(s) in my name from the U.S. Small Business Administration. Please include any known information about the loan (the loan or application number(s), amount(s) or any other details).

___________________________________________________________________________

___________________________________________________________________________

☐ State how you became aware that your identity was used to obtain this/these loan(s):

___________________________________________________________________________

___________________________________________________________________________

☐ I hereby confirm that the loan was not requested by me (or my business) nor did I authorize anyone to submit an application for me (or my business).

☐ I hereby confirm that none of the proceeds of the loan were used by me (or my business) or for my benefit or any other purpose that could benefit me (or my business).

☐ Are you aware of any other uses of your identity to borrow any other money, including obtaining credit cards, or to file state or federal income tax returns, if so please describe:

________________________________________________________________________

________________________________________________________________________

☐ You are required to attach and send with this form an official copy of a police report or an official report filed with a Federal law enforcement agency such as the FTC, FBI or United States Secret Service regarding this matter.

☐ You are required to attach and send with this form a copy of a valid driver license, U.S. Passport, U.S. Military ID, or other valid ID issued by a state or federal agency.

I declare under penalty of perjury pursuant to 28 U.S.C. § 1746 that the information provided in this Declaration is based on my personal information and is true and correct.⁶

______________ ________________________________________

Date Signature of Declarant

PRIVACY ACT (5 U.S.C. § 552a)

The information provided in this form is protected by the Privacy Act, 5 U.S.C 552a, which prohibits the federal government from disclosing personal information about an individual without the individual’s consent. The Privacy Act authorizes SBA to make certain routine uses of information protected by the Act as set forth in its System of Records Notices, 69 F.R. 58598. This form or the information provided in this form may be made available to federal, state, and/or local law enforcement agencies charged with responsibility for or otherwise involved in investigation, prosecution, enforcement or prevention of such violations of law.

Under the provisions of the Privacy Act, you are not required to provide social security numbers. However, if you do not provide the information, it may be more difficult to assist you in resolving your identity theft issue. Note: Any person concerned with the collection, use and disclosure of information, under the Privacy Act may contact the Chief, FOI/ PA Office, 409 3rd Street, SW, Suite 5900, Washington, DC 20416 or by e-mail at [email protected] for information about the Agency's procedures relating to the Privacy Act and the Freedom of Information Act.

PLEASE NOTE: According to the Paperwork Reduction Act, you are not required to respond to this collection of information unless it displays a currently valid OMB Control Number. The estimated burden for completing this form, including time for reviewing instructions, gathering data needed, and completing and reviewing the form is 15 minutes.  Comments or questions on the burden estimates should be sent to U.S. Small Business Administration, Director, Records Management Division, 409 3rd St., SW, Washington DC 20416, and/or SBA Desk Officer, Office of Management and Budget, New Executive Office Building, Rm. 10202, Washington DC 20503. PLEASE DO NOT SEND THE FORM TO THESE ADDRESSES.

1 If you are submitting this form for your business, by checking this box and signing the Declaration, you are indicating that you are an authorized representative of the business or the legal owner of the business.

2 By checking this box and signing the Declaration, you are indicating that you are an authorized representative (as a parent, guardian, or legal guardian) to submit and sign on the minor’s behalf.

3 By checking this box and signing the Declaration, you are indicating that you are the surviving spouse, the Court-Appointed or personal representative, Executor, or Administrator and that you are authorized to submit and sign the Declaration.

4 By checking this box and signing the Declaration, you are indicating that you have a Power of Attorney or are the Court-Appointed Guardian, or Conservator and that you are the authorized to submit and sign the Declaration.

5 Complete if someone other than the Identity Theft Victim is submitting the Declaration.

6WARNING: In addition, any false statement or misrepresentation to SBA may result in criminal, civil or administrative sanctions including, but not limited to: 1) fines, imprisonment, or both, under 15 U.S.C. 645, 18 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.

SBA Form 3513 (01-21)