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pdfOMB Control Number: 3245-0407
Expiration Date: 12/31/2020
PAYCHECK PROTECTION PROGRAM
LOAN NECESSITY QUESTIONNAIRE (FOR-PROFIT BORROWERS)
The purpose of this form is to facilitate the collection of supplemental information that will be used by
SBA loan reviewers to evaluate the good-faith certification that you made on your PPP Borrower
Application (SBA Form 2483 or Lender’s equivalent form) that economic uncertainty made the loan
request necessary. Each for-profit Borrower that, together with its affiliates, 1 received PPP loans with an
original principal amount of $2 million or greater is required to complete this form and submit it, along
with the required supporting documents, to the Lender servicing Borrower’s PPP loan. The completed
form is due to the Lender servicing your PPP loan within ten business days of receipt from your
Lender.
SBA is reviewing these loans to maximize program integrity and protect taxpayer resources. The
information collected will be used to inform SBA’s review of your good-faith certification that economic
uncertainty made your loan request necessary to support your ongoing operations. Receipt of this form
does not mean that SBA is challenging that certification. After this form is submitted, SBA may request
additional information, if necessary, to complete the review. SBA’s determination will be based on the
totality of your circumstances.
Failure to complete the form and provide the required supporting documents may result in SBA’s
determination that you were ineligible for either the PPP loan, the PPP loan amount, or any forgiveness
amount claimed, and SBA may seek repayment of the loan or pursue other available remedies.
Within five business days after you provide a complete form with all required responses, supporting
documents, and signatures and certifications, the Lender servicing your loan is required to upload the
form and documents to the SBA PPP Forgiveness Platform (forgiveness.sba.gov) and separately input
your responses to each question into the web form available in the platform.
Additional instructions are set forth on the next page.
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 questionnaire, including gathering data needed, is 90 minutes. Comments about this time or the
information requested should be sent to 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, Washington DC 20503. PLEASE DO
NOT SEND FORMS TO THESE ADDRESSES.
1
See 85 FR 20817 (April 15, 2020) regarding application of SBA’s affiliation rules.
SBA Form 3509 (10/2020)
Part A – Borrower Information
Business Legal Name (“Borrower”)
Business Address
SBA PPP Loan Number
DBA or Tradename, if applicable
Business TIN (EIN, SSN)
Business Phone
Primary Contact
E-mail Address
Original Principal Amount of PPP Loan ($)
Part B – For-Profit Borrower Questionnaire
Eligible types of for-profit borrowers include sole proprietors, partnerships, C-corporations, Scorporations, limited liability companies, independent contractors, eligible self-employed individuals,
Tribal businesses (sec. 31(b)(2)(C) of Small Business Act), and electric and telephone cooperatives
exempt from federal income taxation under section 501(c)(12) of the Internal Revenue Code.
Instructions:
• For the Business Activity Assessment section below, you must include supporting documentation
for your answers to question #1 as part of your submission.
• For the Liquidity Assessment section below, you must include supporting documentation for your
answers to questions #1, 2.B, 3.B, 4.C, and 5.C as part of your submission.
• For each question, in the right-hand column (labeled “Confidential?”), select “YES” or “NO” to
indicate whether your answers or information provided in response to the question are customarily
kept confidential.
• SBA may request additional supporting documentation as part of the loan review.
Business Activity Assessment
1.
Provide answers and supporting documentation
for questions 1.A and either 1.B or 1.C:
A. What was Borrower’s gross revenue in the
second calendar quarter (Q2) of 2020?
Seasonal borrowers may provide gross
revenue in the third calendar quarter
(Q3) of 2020 instead of Q2 2020.
B. If Borrower existed in Q2 2019, what was
Borrower’s gross revenue in Q2 2019?
Seasonal borrowers that entered gross
revenue in Q3 2020 for question 1.A
must enter gross revenue in Q3 2019.
2
SBA Form 3509 (10/2020)
Confidential?
$
Select
$
Select
2.
3.
C. If Borrower did not exist in Q2 2019, what
was Borrower’s gross revenue in the first
calendar quarter (Q1) of 2020?
$
Seasonal borrowers that entered gross
revenue in Q3 2020 for question 1.A
must enter gross revenue in Q3 2019.
A. Since the COVID-19 National Emergency
Declaration issued by President Trump on
March 13, 2020, has Borrower been ordered
YES
to shut down by a state or local authority due
to COVID-19?
B. If the answer to 2.A is YES, which state or
local authority issued the shutdown order?
Start
C. If the answer to 2.A is YES, provide start
and end dates of the shutdown order (if
ongoing, write “present” under “End”).
A. At any time since March 13, 2020, has
Borrower been ordered to significantly alter
its operations by a state or local authority
due to COVID-19?
B. If the answer to 3.A is YES, provide start
and end dates of the order to alter its
operations (if ongoing, write “present”
under “End”).
YES
Select
NO
Select
Select
End
Select
NO
Start
Select
End
Select
C. If the answer to 3.A is YES, how were
Borrower’s operations altered due to the
order? (select all that apply)
i. The number of people permitted in a
location at one time was reduced or
YES
capped.
ii. Service was restricted to outdoors.
YES
iii. Employee workspaces were
YES
reconfigured.
iv. Other (please describe) [1,000-character max].
NO
Select
NO
Select
NO
Select
Select
D. If the answer to 3.A is YES, what were
Borrower’s approximate additional cash
outlays for these mandatory alterations?
$
3
SBA Form 3509 (10/2020)
Select
4.
A. At any time since March 13, 2020, has
Borrower voluntarily ceased or reduced its
operations due to COVID-19?
B. If the answer to 4.A is YES, provide start
and end dates when Borrower voluntarily
ceased or reduced operations (if ongoing,
write “present” under “End”).
YES
Select
NO
Start
End
Select
C. If the answer to 4.A is YES, why did
Borrower voluntarily cease or reduce
YES
operations? (select all that apply)
i. Employee(s) contracted COVID-19.
ii. COVID-19 significantly disrupted
Borrower’s supply chain (e.g., a supplier
of goods or services that are essential to
YES
Borrower’s operations was unable to
deliver due to COVID-19).
iii. Other (please describe) [1,000-character max].
NO
Select
NO
Select
Select
5.
A. At any time since March 13, 2020, has
Borrower voluntarily altered its operations
due to COVID-19 (other than ceasing or
reducing operations)?
B. If the answer to 5.A is YES, provide start
and end dates when the voluntary
alterations were in place (if ongoing,
write “present” under “End”; if staggered,
provide multiple start and end dates).
C. If the answer to 5.A is YES, how were
Borrower’s operations voluntarily altered?
(select all that apply)
i. The number of people permitted in a
location at one time was reduced or
capped.
ii. Service was restricted to outdoors.
iii. Employee workspaces were
reconfigured.
4
SBA Form 3509 (10/2020)
YES
Select
NO
Start
End
Select
YES
NO
Select
YES
NO
Select
YES
NO
Select
iv. Other (please describe) [1,000-character max].
Select
6.
7.
8.
D. If the answer to 5.A is YES, what were
Borrower’s approximate additional cash
$
outlays for these voluntary alterations?
A. Between March 13, 2020 and the end of the
loan forgiveness covered period of the PPP
loan, did Borrower begin any new capital
YES
improvement projects not due to COVID19?
B. If the answer to 6.A is YES, what were
Borrower’s approximate cash outlays for
$
those projects?
What is Borrower’s primary six-digit NAICS
code?
Optional – provide additional comments on any question in this
Business Activity Assessment section [1,000-character max].
Select
NO
Select
Select
Select
Select
Liquidity Assessment
1.
As of the last day of the calendar quarter
immediately before the date of Borrower’s PPP
loan application, how much did Borrower own
in cash and cash equivalents? Provide
supporting documentation.
2.
A. Between March 13, 2020 and the end of the
loan forgiveness covered period of the PPP
loan, has Borrower paid any dividends or
other capital distributions (other than for
pass-through estimated tax payments 2) to its
owners?
2
Confidential?
$
Select
YES
NO
Select
Distributions made by a partnership or S-corporation that are designed to be used only for owners’ estimated
quarterly tax payments are excepted, as long as they do not exceed the tax liability on profits earned in the first three
quarters of 2020, 110 percent of the pro-rata share of last year’s tax liability on distributions, and/or 100 percent of
the pro-rata share of tax liability on total distributions in 2020.
5
SBA Form 3509 (10/2020)
3.
4.
5.
6.
B. If the answer to 2.A is YES, what was the
total amount of all dividends or other capital
distributions between March 13, 2020 and
the end of the loan forgiveness covered
period of the PPP loan? Provide supporting
documentation.
A. Between March 13, 2020 and the end of the
loan forgiveness covered period of the PPP
loan, has Borrower prepaid any outstanding
debt (i.e., paid before contractually due)?
B. If the answer to 3.A is YES, what was the
total amount of all debt prepayments
between March 13, 2020 and the end of the
loan forgiveness covered period of the PPP
loan? Provide supporting documentation.
A. During the loan forgiveness covered period
of the PPP loan, were any of Borrower’s
employees compensated in an amount that
exceeds $250,000 on an annualized basis?
(Compensation for this purpose covers gross
salary, gross wages, gross tips, gross
commissions, and allowances for dismissal
or separation.)
B. If the answer to 4.A is YES, how many
employees?
C. If the answer to 4.A is YES, what was the
total amount of compensation during the
loan forgiveness covered period of all of
those employees included in the answer to
4.B? Provide supporting documentation.
A. During the loan forgiveness covered period
of the PPP loan, were any of Borrower’s
owners who work at Borrower compensated
by Borrower in an amount that exceeds
$250,000 on an annualized basis?
(Compensation for this purpose covers gross
salary, gross wages, gross tips, gross
commissions, and allowances for dismissal
or separation.)
B. If the answer to 5.A is YES, how many
owners?
C. If the answer to 5.A is YES, what was the
total amount of compensation during the
loan forgiveness covered period of all of
those owners included in the answer to 5.B?
Provide supporting documentation.
A. On the date of Borrower’s PPP loan
application, were any of Borrower’s equity
securities listed on a national securities
exchange?
6
SBA Form 3509 (10/2020)
$
Select
YES
NO
$
Select
Select
YES
NO
Select
Select
$
Select
YES
NO
Select
Select
$
Select
YES
NO
Select
7.
8.
9.
10.
B. If the answer to 6.A is YES, what was
Borrower’s market capitalization on the date
of Borrower’s PPP loan application?
A. On the date of Borrower’s PPP loan
application, did any publicly traded
company own 20 percent or more of any
class of Borrower’s outstanding equity
securities?
B. If the answer to 7.A is YES, what was the
name and market capitalization of the
publicly traded company on the date of
Borrower’s PPP loan application?
Company A (name):
Company B (name):
Company C (name):
Company D (name):
Company E (name):
If the answer to 6.A is NO, what was the book
value (shareholders’ equity value) of Borrower
as of the last day of the calendar quarter
immediately before the date of Borrower’s PPP
loan application?
A. On the date of Borrower’s PPP loan
application, was Borrower a subsidiary of
(i.e., was at least 50 percent of Borrower’s
common equity, or equivalent equity
interest, owned by) another company (the
parent company)?
B. If the answer to 9.A is YES, what was the
name of the parent company?
C. If the answer to 9.A is YES, was the parent
company organized or incorporated under
the laws of a jurisdiction outside the U. S.?
D. If the answer to 9.A is YES, and if any of
the equity securities of Borrower’s parent
company are listed on a national securities
exchange or on a securities exchange in a
non-U.S. jurisdiction, what was the market
capitalization of the parent company on the
date of Borrower’s PPP loan application?
On the date of Borrower’s PPP loan application,
was 20 percent or more of any class of
Borrower’s outstanding equity securities owned
by a private equity firm, venture capital firm, or
hedge fund (including a fund managed by any
such firm)?
7
SBA Form 3509 (10/2020)
Select
$
YES
NO
Select
$
$
$
$
$
Select
Select
Select
Select
Select
$
Select
YES
NO
Select
Select
YES
NO
$
Select
Select
YES
NO
Select
11.
12.
A. On the date of Borrower’s PPP loan
application, was Borrower an affiliate 3 or a
subsidiary (i.e., was at least 50 percent of
Borrower’s common equity, or equivalent
equity interest, directly or indirectly owned
YES
NO
or controlled by) of a foreign, state-owned
enterprise (i.e., a company at least 50
percent owned by a foreign state) or of a
department, agency, or instrumentality of a
foreign state?
B. If the answer to 11.A is YES, what was the
name of the foreign, state-owned enterprise
or of the foreign state’s department, agency,
or instrumentality?
A. Did Borrower directly receive any funds
from any CARES Act program other than
YES
NO
PPP, excluding tax benefits?
B. If the answer to 12.A is YES, please provide
$
funding amount.
C. If the answer to 12.A is YES, please provide the program name
or describe the funding source. [1,000-character max]
Select
Select
Select
Select
Select
13.
Optional – provide additional comments on any question in this
Liquidity Assessment section[1,000-character max].
Select
3
For purposes of this question, apply the affiliation test as described in SBA’s interim final rule on affiliates, 85 FR
20817 (April 15, 2020).
8
SBA Form 3509 (10/2020)
CERTIFICATIONS
The Authorized Representative of Borrower must certify to all of the below by initialing next to each item:
_______ I certify that I have the authority to sign and submit this questionnaire on behalf of the Borrower.
_______ I certify that the information provided in this questionnaire and in all supporting documentation is
true and correct in all material respects. I make this certification after reasonable inquiry of people,
systems, and other information available to the Borrower.
_______ I understand that knowingly making a false statement to obtain a guaranteed loan or forgiveness of
an SBA-guaranteed loan 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.
__________________________________________
Signature of Authorized Representative of Borrower
__________________________________________
Print Name
__________________________________________
Title
__________________________________________
Date
9
SBA Form 3509 (10/2020)
| File Type | application/pdf |
| File Modified | 2020-11-30 |
| File Created | 2020-10-16 |