Form SBA Form 3172 SBA Form 3172 Restaurant Revitalization Fund Application

		OMB Control No.: 3245-XXXX
	U.S. SMALL BUSINESS ADMINISTRATION	Expiration Date: XX/XX/XXXX
	RESTAURANT REVITALIZATION FUNDING APPLICATION

This application is to be completed by applicants who are applying for funding under the Restaurant Revitalization Program. SBA is collecting the requested information to determine whether applicants are eligible for funding.

SBA may provide funding of up to $5,000,000 per location (not to exceed $10,000,000 total for the Applicant and any affiliated businesses) for Applicants who meet certain conditions. The minimum award will be $1,000; therefore, applications for less than $1,000 will not be accepted. See application instructions for counting locations.

Awardees will not be required to repay funds received under the Restaurant Revitalization Program unless the funds were used for purposes other than for authorized purposes, if the funds were not used by March 11, 2023, or if applicable, the awardee permanently closed before using all funds on authorized purposes.

Your response to this application is required for SBA to make a determination regarding your eligibility.

Complete the entire application, placing your initials and signature where indicated. Submit your completed application and all required documentation to SBA. SBA may deny your application if it is incomplete or lacks required documentation.

Submission of the application does not guarantee approval of the application or an award of funds.

Business Legal Name (if sole proprietor, enter first and last name):

__________________________________________________

“Doing Busines As” Name if different than Business Legal Name:

__________________________________________________

Business Address (Street, City, State, Zip Code) For Applicants that conduct sales from permanent structures, enter the main location. For Applicants that operate mobile food trucks, carts, etc., enter the address of the business headquarters. Attach a separate sheet if necessary. P.O. Boxes are not permitted:

__________________________________________________________________________

____________________________________________________________________________________

Business Tax Identification Number (EIN, SSN, ITIN): ___________________

ACH Information for account where funds are to be deposited:

Name of Lending Institution: ____________________________________

Routing Number: _____________________ Account Number: _________________________

Check one: ☐ Checking Account ☐ Savings Account

Applicant Ownership: List all owners of 20% or more of the equity of the Applicant. If no owner has at least 20% ownership of the Applicant, you must list enough owners whose combined equity represents at least 20% of the ownership of the Applicant. Listed equity does not have to total to 100% of ownership. Attach a separate sheet if necessary.

Owner #1 Name: _______________________________________

• Owner #1 Tax Identification Number (EIN, SSN, ITIN): ___________________

• Owner #1 Percentage of Ownership: _______%

• Owner #1 Address: _______________________________________________

Owner #2 Name: _______________________________________

• Owner #2 Tax Identification Number (EIN, SSN, ITIN): ___________________

• Owner #2 Percentage of Ownership: _______%

• Owner #2 Address: _______________________________________________

Owner #3 Name: _______________________________________

• Owner #3 Tax Identification Number (EIN, SSN, ITIN): ___________________

• Owner #3 Percentage of Ownership: _______%

• Owner #3 Address: _______________________________________________

Owner #4 Name: _______________________________________

• Owner #4 Tax Identification Number (EIN, SSN, ITIN): ___________________

• Owner #4 Percentage of Ownership: _______%

• Owner #4 Address: _______________________________________________

Applicant Form of Organization:

☐ C-Corporation

☐ S-Corporation

☐ Partnership

☐ Limited Liability Company

☐ Sole Proprietorship, Self-employed, or Independent Contractor

☐ Tribal business

Applicant must review and respond to all of the following questions. PLEASE SEE APPLICATION INSTRUCTIONS FOR INFORMATION ON COMPLETING THIS APPLICATION.

1. The Applicant’s business:

a. Is a State or local government-operated business: ☐ No ☐ Yes (if Yes, the Applicant is not eligible)

b. As of March 13, 2020, owns or operates (together with any affiliated business) more than 20 locations, regardless of whether those locations do business under the same or multiple names.

☐ No ☐ Yes (if Yes, the Applicant is not eligible)

c. Has a pending application for or has received a Shuttered Venue Operators Grant

☐ No ☐ Yes (if Yes, the Applicant is not eligible)

d. Is a publicly-traded company (defined as an entity that is majority owned or controlled by an entity that is an issuer, the securities of which are listed on a national securities exchange)

☐ No ☐ Yes (if Yes, the Applicant is not eligible)

2. Which of the following best describes the Applicant’s business? Check all that apply.

☐ Restaurant

☐ Food stand, food truck, food cart

☐ Caterer

☐ Bar, saloon, lounge, tavern

☐ Brewpub, tasting room, taproom (Eligibility requires onsite sales to the public comprising at least 33% of gross receipts)

☐ Inn (Eligibility requires onsite sales of food and beverage to the public comprising at least 33% of gross receipts)

☐ Licensed facility or premise of a beverage alcohol producer where the public may taste, sample, or purchase products

☐ Other similar place of business in which the public or patrons assemble for the primary purpose of being served food or drink

☐ Snack and Nonalcoholic Beverage Bar

☐ Bakery (Eligibility requires onsite sales to the public comprising at least 33% of gross receipts)

☐ Brewery and/or microbrewery (Eligibility requires onsite sales to the public comprising at least 33% of gross receipts)

☐ Winery (Eligibility requires onsite sales to the public comprising at least 33% of gross receipts)

☐ Distillery (Eligibility requires onsite sales to the public comprising at least 33% of gross receipts)

3. Is the Applicant’s business permanently closed?

☐ No (Check “No” if you are temporarily closed or are actively working on opening)

☐ Yes (Applicant is not eligible)

4. Is the Applicant currently in bankruptcy?

☐ No (Applicant is eligible)

☐ Yes – Operating under an approved plan of reorganization under either a Chapter 11, Chapter 12 or Chapter 13 bankruptcy (Applicant is eligible)

☐ Yes – Filed for either a Chapter 11, Chapter 12 or Chapter 13 bankruptcy but no plan of reorganization has been approved (Applicant is not eligible)

☐ Yes – Filed for a Chapter 7 bankruptcy, is undergoing a liquidating Chapter 11, and/or is permanently closed (Applicant is not eligible)

5. Did the Applicant receive a First Draw Paycheck Protection Program (PPP) loan (First Draw PPP Loan) at any time in 2020 or 2021?

☐ No

☐ Yes

If Yes: How much did you receive (or will receive)? $______________

SBA PPP Loan Number: ______________

Do not include any amount that you repaid on or before May 18, 2020 in accordance with PPP safe harbor rules.

6. Did the Applicant receive a Second Draw Paycheck Protection Program (PPP) loan (Second Draw PPP Loan) in 2021?

☐ No

☐ Yes

If Yes: How much did you receive (or will receive)? $______________

SBA PPP Loan Number: ______________

7. Does the Applicant have affiliates?

☐ No

☐ Yes

7.(a) If yes, how many affiliates does the Applicant have?

____________

7.(b) Please list each affiliate’s legal business name (attach extra sheet if necessary):

___________________________________________________________________________

8. What date did you begin making sales? (Month, Day, Year or N/A if not applicable) ___________________

Calculation of Funding Amount

For Applicants that were in operation prior to or on January 1, 2019:

1	Enter 2019 gross receipts as reported on your 2019 Federal tax return:		$
2	Enter 2020 gross receipts as reported or to be reported on your 2020 Federal tax return. Do not include any amounts received from any Paycheck Protection Program (PPP) loan, SBA Section 1112 debt relief payments, or from any SBA Economic Injury Disaster Loan (EIDL) loan, EIDL advance, targeted EIDL advance, state and local small business grants (via CARES Act or otherwise).	$	$
3	Enter the total amount(s) of PPP loan(s) (First Draw PPP Loan and Second Draw PPP Loan) received, regardless of whether you received funds in 2020 or 2021. Do not include any amount that you repaid on or before May 18, 2020 in accordance with PPP safe harbor rules.	$
4	Add lines 2 and 3 together	$
5	Subtract line 4 from line 1	Line 1 – line 4=	$
6	Enter the number of locations operated by the Applicant
7	Multiply line 6 by $5,000,000.	Line 6 X $5,000,000=
8	If line 7 is less than line 5: Enter the amount from line 7 If line 5 is less than line 7: Enter the amount from line 5	Enter whichever is smaller, line 7 or line 5	$
9	Adjust for maximum limit to you and your affiliates. Reduce line 8 so that your funding amount, together with your affiliates is no more than $10,000,000. If you do not have affiliates, or if your grant, together with your affiliates, is $10,000,000 or less, enter the amount from line 8. THIS IS YOUR FUNDING AMOUNT REQUESTED.		$

Calculation of Funding Amount

For Applicants that began operations partially through 2019:

1(a)	Enter 2019 gross receipts as reported on your 2019 Federal tax return:		$
1(b)	Enter the number of months you were in operation in 2019. For example, if you were open for 2 ½ months, enter 2.5. Round to the tenth decimal (e.g. 2.5)
1(c)	Divide line 1(a) by line 1(b) This is your average monthly gross receipts.	Line 1(a) / line 1(c)=	$
1(d)	Multiply line 1(c) by 12 This is your annualized 2019 gross receipts.	Line 1(c) X 12=	$
2	Enter 2020 gross receipts as reported or to be reported on your 2020 Federal tax return. Do not include any amounts received from any Paycheck Protection Program (PPP) loan, SBA Section 1112 debt relief payments, or from any SBA Economic Injury Disaster Loan (EIDL) loan, EIDL advance, targeted EIDL advance, state and local small business grants (via CARES Act or otherwise).	$	$
3	Enter the total amount(s) of PPP loan(s) (First Draw PPP Loan and Second Draw PPP Loan) received, regardless of whether you received funds in 2020 or 2021. Do not include any amount that you repaid on or before May 18, 2020 in accordance with PPP safe harbor rules.	$
4	Add lines 2 and 3 together	$
5	Subtract line 4 from line 1(d)	Line 1(d) – Line 4=	$
6	Enter the number of locations operated by the Applicant
7	Multiply line 6 by $5,000,000.	Line 6 X $5,000,000=
8	If line 7 is less than line 5: Enter the amount from line 7 If line 5 is less than line 7: Enter the amount from line 5	Enter whichever is smaller, line 7 or line 5	$
9	Adjust for maximum limit to you and your affiliates. Reduce line 8 so that your grant amount, together with your affiliates is no more than $10,000,000. If you do not have affiliates, or if your grant, together with your affiliates, is $10,000,000 or less, enter the amount from line 8. THIS IS YOUR FUNDING AMOUNT REQUESTED.		$

Calculation of Funding Amount

For Applicants that began operations on or between January 1, 2020 and March 10, 2021; and For Applicants that have not yet opened but as of March 11, 2021, have incurred eligible expenses:

1	Enter the amount you spent on eligible expenses. Eligible expenses have the same definition as eligible uses of funds:		$
2	Enter all gross receipts as of application signature date. Do not include any amounts received from any Paycheck Protection Program (PPP) loan, SBA Section 1112 debt relief payments, or from any SBA Economic Injury Disaster Loan (EIDL) loan, EIDL advance, targeted EIDL advance, state and local small business grants (via CARES Act or otherwise).	$	$
3	Enter the total amount(s) of PPP loan(s) (First Draw PPP Loan and Second Draw PPP Loan) received, regardless of whether you received funds in 2020 or 2021. Do not include any amount that you repaid on or before May 18, 2020 in accordance with PPP safe harbor rules.	$
4	Add lines 2 and 3 together	$
5	Subtract line 4 from line 1	Line 1 – line 4=	$
6	Enter the number of locations operated by the Applicant
7	Multiply line 6 by $5,000,000.	Line 6 X $5,000,000=
8	If line 7 is less than line 5: Enter the amount from line 7 If line 5 is less than line 7: Enter the amount from line 5	Enter whichever is smaller, line 7 or line 5	$
9	Adjust for maximum limit to you and your affiliates. Reduce line 8 so that your grant amount, together with your affiliates is no more than $10,000,000. If you do not have affiliates, or if your grant, together with your affiliates, is $10,000,000 or less, enter the amount from line 8. THIS IS YOUR FUNDING AMOUNT REQUESTED.		$

Purpose of the Restaurant Revitalization Funds (select all that apply)

☐ Business Payroll Costs, including paid sick leave

☐ Business Rent / Business Mortgage

☐ Business Debt Service

☐ Business Utilities

☐ Business Food and beverage expenses, including raw materials

☐ Business Maintenance Expenses

☐ Construction of Outdoor Seating

☐ Business Supplies

☐ Covered Supplier Costs

☐ Business Operating Expenses

Priority in Awarding Restaurant Revitalization Funds

In accordance with the American Rescue Plan Act of 2021, SBA will prioritize awarding funds to Applicants that are small business concerns at least 51 percent owned and controlled by individuals who are women, veterans, and/or socially and economically disadvantaged individuals. Applicants in one of these categories that are operating under an approved plan of reorganization under either a Chapter 11, Chapter 12 or Chapter 13 bankruptcy and do not have a trustee exercising day-to-day control are eligible for funding under this program. See the application instructions for applicable definitions.

As of the date of this application, Applicant is a small business concern at least 51 percent owned and controlled by (check all that apply):

☐ One or more women

☐ Veteran(s)

☐ Socially and economically disadvantaged individual(s)

Self-Certification that Applicant is Eligible for Priority in Awarding Restaurant Revitalization Funds:

The authorized representative of the Applicant must self-certify that the Applicant is eligible for priority in awarding grants because the Applicant is an eligible small business concern owned and controlled by one or more women, veterans, and/or socially and economically disadvantaged individuals by initialing here:________

Required Documentation (Application will not be accepted without the following):

(1) For all Applicants:

☐ This application, completed, initialed, and signed; completion of this form digitally on the SBA Grant Platform will satisfy this requirement.

☐ IRS Form 4506-T, completed and signed by Applicant. Completion of this form digitally on the SBA Grant Platform will satisfy this requirement.

☐ Any of the following documents demonstrating gross receipts

Applicants that were in operation prior to or on January 1, 2019, must supply documentation of gross receipts for 2019 and 2020;

Applicants that began operations partially through 2019, must supply documentation of gross receipts for 2019 and 2020;

Applicants that began operations on or between January 1, 2020 and ending on March 10, 2021 and Applicants that have not yet opened but as of March 11, 2021, but have incurred eligible expenses, must supply documentation of gross receipts and eligible expenses for the length of time in operations.

Acceptable documentation of gross receipts and, if applicable, eligible expenses, includes the following:

• Business tax returns (IRS Form 1120 or IRS 1120-S);

• IRS Forms 1040 Schedule C; IRS Forms 1040 Schedule F;

• For a partnership: partnership’s IRS Form 1065 (including K-1s);

• Bank statements;

• Externally or internally prepared financial statements such as Income Statements or Profit and Loss Statements;

• Point of sale report(s), including IRS Form 1099-K.

(2) For Applicants that are a brewpub, tasting room, taproom, brewery, winery, distillery, or bakery: In addition to the documents in (1) above, documents evidencing that onsite sales to the public comprise at least 33% of gross receipts for each of the years included in your funding calculation, which may include Tax and Trade Bureau reports filed or to be filed that cover the period for which you are reporting gross receipts, or if applicable, eligible expenses.

(3) For Applicants that are an Inn: In addition to the documents in (1) above, documents evidencing that onsite sales of food and beverage to the public comprise at least 33% of gross receipts for each of the years included in your funding calculation.

Self-Certification for all Applicants:

The authorized representative of the Applicant must certify in good faith to all of the below by initialing next to each one:

The Applicant business has not permanently closed.

Current economic uncertainty makes this funding request necessary to support the ongoing or anticipated operations of the Applicant.

I understand that the Applicant business must use all funds only on eligible uses within the covered period, which is the period beginning on February 15, 2020 and ending on March 11, 2023. If the business permanently closes, the covered period will end when the business permanently closes or on March 11, 2023, whichever occurs sooner. Awardees that are unable to use all of the funds received on eligible expenses by the end of the covered period must return any unused funds to Treasury.

The Applicant, together with its affiliates, does not own or operate more than 20 locations, regardless of whether those locations do business under the same or different names.

The Applicant has not applied for or received a Shuttered Venue Operator grant from SBA.

The Applicant is not a publicly-traded company (publicly-traded company is defined as an entity that is majority owned or controlled by an entity that is an issuer, the securities of which are listed on a national securities exchange under section 6 of the Securities Exchange Act of 1934).

I further certify that the information provided in this application and the information provided in all supporting documents and forms is true and accurate in all material respects. I understand that knowingly making a false statement to obtain a grant from SBA is punishable under the law, including under 18 U.S.C. 1001 and 3571 by imprisonment of not more than five years and/or a fine of up to $250,000; under 15 U.S.C. 645 by imprisonment of not more than two years and/or a fine of not more than $5,000; and, if submitted to a federally insured institution, under 18 U.S.C. 1014 by imprisonment of not more than thirty years and/or a fine of not more than $1,000,000.

I acknowledge that SBA will check Applicant identification data against the Treasury Do Not Pay (DNP) lists and that the Applicant is ineligible if it is listed on the DNP lists.

I acknowledge that by submitting this funding application any pending PPP application or future PPP application will be declined by SBA in order to ensure proper reduction of the amount.

I acknowledge that SBA will confirm Applicant eligibility for funding under the Restaurant Revitalization Program. I acknowledge that SBA may select my application for audit or review, and I certify that I will provide SBA with requested documentation. I understand, acknowledge, and agree that the Internal Revenue Service can share any tax information that I have provided with SBA’s authorized representatives, including authorized representatives of the SBA Office of Inspector General, for the purpose of compliance with all applicable program requirements, regulations, and laws.

Applicant Demographic Information (Optional)

This data is collected for program reporting purposes only. Disclosure is voluntary and will have no bearing on the application decision.

Principal Name	Position

	Select Response Below:
Veteran	☐ Non-Veteran ☐ Veteran ☐ Service-Disabled Veteran ☐ Spouse of Veteran ☐ Not Disclosed
Gender	☐ Male ☐ Female ☐ Not Disclosed
Race (more than 1 may be selected)	☐ American Indian or Alaska Native ☐ Asian ☐ Black or African-American ☐ Native Hawaiian or Pacific Islander ☐ White ☐ Not Disclosed
Ethnicity	☐ Hispanic or Latino ☐ Not Hispanic or Latino ☐ Not Disclosed

Name of Authorized Representative of the Applicant (The individual who is signing the application on behalf of the Applicant and who will receive all communication from SBA):

First Name: ________________________ Last Name: ______________________________

Business Phone: ___________________________ Title: _______________________________

Email Address: _______________________ (If none, SBA will mail correspondence to business address)

______________________________________________ ________________________

Signature of Authorized Representative of Applicant Date

Purpose of this form:

This form is to be completed by the authorized representative of the Applicant and submitted in accordance with page 1 of the application. Submission of the requested information is required to make a determination regarding eligibility for financial assistance. Failure to submit the information would affect that determination.

Instructions for completing this form:

Eligible uses of funds are: (1) Business payroll costs, including sick leave and costs related to the continuation of group health care, life, disability, vision, or dental benefits during periods of paid sick, medical, or family leave, and group health care, life, disability, vision, or dental insurance premiums; Payroll costs consist of compensation to employees (whose principal place of residence is the United States) in the form of salary, wages, commissions, or similar compensation; cash tips or the equivalent (based on employer records of past tips or, in the absence of such records, a reasonable, good-faith employer estimate of such tips); payment for vacation, parental, family, medical, or sick leave (except qualified wages (as defined in subsection (c)(3) of section 2301 of the CARES Act) taken into account in determining the credit allowed under such section 2301; or premiums taken into account in determining the credit allowed under section 6432 of the Internal Revenue Code of 1986); allowance for separation or dismissal; payment for the provision of employee benefits (including insurance premiums) consisting of group health care coverage, group life, disability, vision, or dental insurance, and retirement benefits; payment of state and local taxes assessed on compensation of employees; and, for an independent contractor or sole proprietor, wage, commissions, income, or net earnings from self-employment or similar compensation. (2) Payments of principal or interest on any business mortgage obligation (which may not include any prepayment of principal on a mortgage obligation); (3) Business rent payments, including rent under a lease agreement (which may not include any prepayment of rent); (4) Business debt service; (5) Business utility payments for the distribution of electricity, gas, water, telephone, or internet access for which service began before February 15, 2020 ; (6) Business maintenance expenses including maintenance on walls, floors, deck surfaces, furniture, fixtures, and equipment; (7) Construction of outdoor seating; (8) Supplies, including protective equipment and cleaning materials; (9) Food and beverage expenses including raw materials for beer or spirits; (10) Covered supplier costs, which is an expenditure made by the eligible entity to a supplier of goods for the supply of goods that: Are essential to the operations of the entity at the time at which the expenditure is made; and is made pursuant to a contract, order, or purchase order in effect at any time before the receipt of funds; or with respect to perishable goods, in effect before or at any time during the covered period (11) Business operating expenses, which is defined as business expenses incurred through normal business operations that are necessary and mandatory for the business (e.g. rent, equipment, inventory, marketing, insurance). Business operating expenses do not include expenses that occur outside of a company’s day-to-day activities.

For purposes of reporting locations: Count each place where the Applicant conducts sales from a permanent structure. If the Applicant conducts sales from multiple permanent locations, list each address. For Applicants that operate mobile food trucks, carts, etc., enter the address of the business headquarters.

Tax Identification Numbers: Applicant must provide tax identification numbers (TIN) for the Applicant business and all owners of 20% or more of the equity of the Applicant. TINs may be Employer Identification Numbers, Social Security Numbers, or Individual Taxpayer Identification Numbers assigned by the Internal Revenue Service.

All parties listed below are considered owners of the Applicant:

 For a sole proprietorship, the sole proprietor;

 For a partnership, all general partners, and all limited partners owning 20% or more of the equity of the firm;

 For a corporation, all owners of 20% or more of the corporation;

 For limited liability companies, all members owning 20% or more of the company; and

 Any Trustor (if the Applicant is owned by a trust).

Demographic Information: For purposes of reporting (optional) demographic information:

1. Purpose. Veteran/gender/race/ethnicity data is collected for program reporting purposes only.

2. Description. This form requests information about each of the Applicant’s Principals. Add additional sheets if necessary.

3. Definition of Principal. The term “Principal” means:

• For a self-employed individual, independent contractor, or a sole proprietor, the self-employed individual, independent contractor, or sole proprietor.

• For a partnership, all general partners and all limited partners owning 20% or more of the equity of the Applicant, or any partner that is involved in the management of the Applicant’s business.

• For a corporation, all owners of 20% or more of the Applicant, and each officer and director.

• For a limited liability company, all members owning 20% or more of the Applicant, and each officer and director.

• Any individual hired by the Applicant to manage the day-to-day operations of the Applicant (“key employee”).

• Any trustor (if the Applicant is owned by a trust).

• For a nonprofit organization, the officers and directors of the Applicant.

4. Principal Name. Insert the full name of the Principal.

5. Principal Position. Identify the Principal’s position; for example, self-employed individual; independent contractor; sole proprietor; general partner; owner; officer; director; member; or key employee.

Affiliate/Affiliated Business: An Affiliated Business or affiliate is a business in which an eligible entity has an equity interest or right to profit distributions of not less than 50 percent, or in which an eligible entity has the contractual authority to control the direction of the business, provided that such affiliation shall be determined as of any arrangements or agreements in existence as of March 13, 2020.

Priority in Awarding Restaurant Revitalization Funds: To be eligible for priority in awarding Restaurant Revitalization Funds, Applicants must self-certify that they meet the definition of any of the following priority Applicants:

• A small business concern owned and controlled by veterans is a business concern (a business entity organized for profit, with a place of business located in the United States, and which operates primarily in the United States) that is considered small in accordance with SBA’s size standards at 13 CFR § 121.201 and is at least 51 percent owned by one or more veterans, and the management and daily business operations of the Applicant are controlled by one or more veterans. A veteran is defined as a person who served in the active military, naval, or air service, and who was discharged or released under conditions other than dishonorable.

• A small business concern owned and controlled by women is a business concern (a business entity organized for profit, with a place of business located in the United States, and which operates primarily in the United States) that is considered small in accordance with SBA’s size standards at 13 CFR § 121.201 and is at least 51 percent owned by one or more women, and the management and daily business operations of the Applicant are controlled by one or more women.

• A small business concern owned and controlled by socially and economically disadvantaged individuals is a business concern (a business entity organized for profit, with a place of business located in the United States, and which operates primarily in the United States) that is considered small in accordance with SBA’s size standards at 13 CFR § 121.201 and is at least 51 percent owned by one or more socially and economically disadvantaged individuals or an economically disadvantaged Indian tribe (including Alaska Native Corporations), or an economically disadvantaged Native Hawaiian Organization, and the management and daily business operations of the Applicant are controlled by one or more socially and economically disadvantaged individuals or an economically disadvantaged Indian tribe, or an economically disadvantaged Native Hawaiian Organization. Socially disadvantaged individuals are those who have been subjected to racial or ethnic prejudice or cultural bias because of their identity as a member of a group without regard to their individual qualities. Individuals who are members of the following groups are presumed to be socially disadvantaged: Black Americans; Hispanic Americans; Native Americans (including Alaska Natives and Native Hawaiians); Asian Pacific Americans; or Subcontinent Asian Americans. Economically disadvantaged individuals are those socially disadvantaged individuals whose ability to compete in the free enterprise system has been impaired due to diminished capital and credit opportunities as compared to others in the same business area who are not socially disadvantaged. In determining the degree of diminished credit and capital opportunities, SBA will consider, but not be limited to, the assets and net worth of such socially disadvantaged individual. In determining the economic disadvantage of an Indian tribe, SBA will consider, where available, information such as the following: the per capita income of members of the tribe excluding judgment awards, the percentage of the local Indian population below the poverty level, and the tribe's access to capital markets.

• SBA will consider an applicant to meet the definition of a small business concern owned and controlled by women, veterans, or socially and economically disadvantaged individuals if the applicant is a small business concern that is at least 51 percent owned by one or more individuals who are women, veterans, or socially and economically disadvantaged and if the management and daily business operations of the applicant are controlled by one or more women, veterans, or socially and economically disadvantaged individual. For example: An applicant has five owners who each own 20 percent of the applicant. Two owners are veterans and one owner is a socially and economically disadvantaged individual. SBA will consider this applicant to meet the requirement that at least 51 percent of the applicant is owned by a priority group.

• If an individual meets the requirements of more than one priority group category, that individual is only counted once. For example: An applicant has five owners who each own 20 percent of the applicant. One of the owners is a woman veteran who is a socially and economically disadvantaged individual; however, none of the remaining four owners are a woman, veteran, or socially and economically disadvantaged individual. This applicant is not eligible to file an application as a priority group applicant. The applicant’s management and daily business operations must also be controlled by one or more women, veterans, or socially and economically disadvantaged individuals.

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 time for completing this application, including gathering data needed, is 45 minutes. Comments about this time or the information requested should be sent to: Small Business Administration, Director, Records Management Division, 409 3^rd St., SW, Washington DC 20416, and/or SBA Desk Officer, Office of Management and Budget, New Executive Office Building, Washington DC 20503. PLEASE DO NOT SEND COMPLETED FORMS TO THESE ADDRESSES.

Privacy Act (5 U.S.C. 552a) – Under the provisions of the Privacy Act, you are not required to provide your social security number. Failure to provide your social security number may not affect any right, benefit, or privilege to which you are entitled. (But see Debt Collection Notice regarding taxpayer identification number below.) Disclosures of name and other personal identifiers are required to provide SBA with sufficient information to make a character determination. When evaluating character, SBA considers the person’s integrity, candor, and disposition toward criminal actions. Additionally, SBA is specifically authorized to verify your criminal history, or lack thereof, pursuant to section 7(a)(1)(B), 15 U.S.C. Section 636(a)(1)(B) of the Small Business Act.

Disclosure of Information – Requests for information about another party may be denied unless SBA has the written permission of the individual to release the information to the requestor or unless the information is subject to disclosure under the Freedom of Information Act. The Privacy Act authorizes SBA to make certain “routine uses” of information protected by that Act. One such routine use is the disclosure of information maintained in SBA’s system of records when this information indicates a violation or potential violation of law, whether civil, criminal, or administrative in nature. Specifically, SBA may refer the information to the appropriate agency, whether Federal, State, local or foreign, charged with responsibility for, or otherwise involved in investigation, prosecution, enforcement, or prevention of such violations. Another routine use is disclosure to other Federal agencies conducting background checks but only to the extent the information is relevant to the requesting agencies’ function. See, 74 F.R. 14890 (2009), and as amended from time to time for additional background and other routine uses. In addition, the CARES Act, requires SBA to register every loan made under the Paycheck Protection Program using the Taxpayer Identification Number (TIN) assigned to the borrower.

Debt Collection Act of 1982, Deficit Reduction Act of 1984 (31 U.S.C. 3701 et seq. and other titles) – SBA must obtain your taxpayer identification number when you apply for a loan. If you receive a loan, and do not make payments as they come due, SBA may: (1) report the status of your loan(s) to credit bureaus, (2) hire a collection agency to collect your loan, (3) offset your income tax refund or other amounts due to you from the Federal Government, (4) suspend or debar you or your company from doing business with the Federal Government, (5) refer your loan to the Department of Justice, or (6) take other action permitted in the loan instruments.

Right to Financial Privacy Act of 1978 (12 U.S.C. 3401) – The Right to Financial Privacy Act of 1978, grants SBA access rights to financial records held by financial institutions that are or have been doing business with you or your business including any financial institutions participating in a loan or loan guaranty. SBA is only required provide a certificate of its compliance with the Act to a financial institution in connection with its first request for access to your financial records. SBA’s access rights continue for the term of any approved loan guaranty agreement. SBA is also authorized to transfer to another Government authority any financial records concerning an approved loan or loan guarantee, as necessary to process, service or foreclose on a loan guaranty or collect on a defaulted loan guaranty.

Freedom of Information Act (5 U.S.C. 552) – This law provides, with some exceptions, that SBA must supply information reflected in agency files and records to a person requesting it. Information about approved loans that is generally released includes, among other things, statistics on our loan programs (individual borrowers are not identified in the statistics) and other information such as the names of the borrowers, the amount of the loan, and the type of the loan. Proprietary data on a borrower would not routinely be made available to third parties. All requests under this Act are to be addressed to the nearest SBA office and be identified as a Freedom of Information request.

Occupational Safety and Health Act (15 U.S.C. 651 et seq.) – The Occupational Safety and Health Administration (OSHA) can require businesses to modify facilities and procedures to protect employees. Businesses that do not comply may be fined and required to abate the hazards in their workplaces. They may also be ordered to cease operations posing an imminent danger of death or serious injury until employees can be protected. Signing this form is certification that the applicant, to the best of its knowledge, is in compliance with the applicable OSHA requirements, and will remain in compliance during the life of the loan.

Civil Rights (13 C.F.R. 112, 113, 117) – All businesses receiving SBA financial assistance must agree not to discriminate in any business practice, including employment practices and services to the public on the basis of categories cited in 13 C.F.R., Parts 112, 113, and 117 of SBA Regulations. All borrowers must display the "Equal Employment Opportunity Poster" prescribed by SBA.

Equal Credit Opportunity Act (15 U.S.C. 1691) – Creditors are prohibited from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status or age (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant’s income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act.

Debarment and Suspension Executive Order 12549 (2 C.F.R. Part 180 and Part 2700) – By submitting this loan application, you certify that neither the Applicant or any owner of the Applicant have within the past three years been: (a) debarred, suspended, declared ineligible or voluntarily excluded from participation in a transaction by any Federal Agency; (b) formally proposed for debarment, with a final determination still pending; (c) indicted, convicted, or had a civil judgment rendered against you for any of the offenses listed in the regulations or (d) delinquent on any amounts owed to the U.S. Government or its instrumentalities as of the date of execution of this certification.

SBA Form 3172 (04-21) Page 1