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pdfOMB Control Number: 3245-0407
Expiration Date: 12/31/2020
PAYCHECK PROTECTION PROGRAM
LOAN NECESSITY QUESTIONNAIRE (NON-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 non-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 3510 (10/2020)
1
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 – Non-Profit Borrower Questionnaire
Eligible types of non-profit borrowers include 501(c)(3) non-profits; 501(c)(19) veterans organizations;
non-profit hospitals owned by governmental entities if they are described in Internal Revenue Code (IRC)
§ 501(c)(3) (or otherwise adhere to the parameters of IRC § 501(c)(3) and rely on the income exclusion
under IRC § 115) and receive less than 50 percent of their funding from state or local government
sources, exclusive of Medicaid; and churches (including temples, mosques, synagogues, and other houses
of worship), conventions or associations of churches, and integrated auxiliaries of churches that meet the
requirements of IRC § 501(c)(3) (even if they have not applied to the IRS to receive recognition of taxexempt status).
Instructions:
• For the Non-Profit Activity Assessment section below, you must include supporting
documentation for your answers to questions #1, 2, and 3 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.C, and 5.B 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.
Non-Profit Activity Assessment
1.
Provide answers and supporting documentation
for questions 1.A and either 1.B or 1.C:
A. What were Borrower’s gross receipts 2 in
the second calendar quarter (Q2) of 2020?
Seasonal borrowers may provide gross
receipts in the third calendar quarter
(Q3) of 2020 instead of Q2 2020.
2
Confidential?
$
Select
The amount of gross receipts provided to questions 1.A, 1.B, and 1.C must include gross receipts from gifts,
grants, contributions, and similar amounts.
SBA Form 3510 (10/2020)
2
2.
3.
B. If Borrower existed in Q2 2019, what were
Borrower’s gross receipts in Q2 2019?
Seasonal borrowers that entered gross
receipts in Q3 2020 for question 1.A
must enter gross receipts in Q3 2019.
C. If Borrower did not exist in Q2 2019, what
were Borrower’s gross receipts in the first
calendar quarter (Q1) of 2020?
Seasonal borrowers that entered gross
receipts in Q3 2020 for question 1.A
must enter gross receipts in Q3 2019.
Provide answers and supporting documentation
for questions 2.A and either 2.B or 2.C:
A. What were Borrower’s gross receipts from
gifts, grants, contributions, and similar
amounts in Q2 2020?
Seasonal borrowers may provide gross
receipts in Q3 2020 instead of Q2 2020.
B. If Borrower existed in Q2 2019, what were
Borrower’s gross receipts from gifts, grants,
contributions, and similar amounts in Q2
2019?
Seasonal borrowers that provided gross
receipts in Q3 2020 for question 2.A
must provide gross receipts in Q3 2019.
C. If Borrower did not exist in Q2 2019, what
were Borrower’s gross receipts from gifts,
grants, contributions, and similar amounts
in Q1 2020?
Seasonal borrowers that provided gross
receipts in Q3 2020 for question 2.A
must provide gross receipts in Q3 2019.
Provide answers and supporting documentation
for questions 3.A and either 3.B or 3.C:
A. What were Borrower’s expenses in Q2
2020?
Seasonal borrowers may enter expenses
in Q3 2020 instead of Q2 2020.
B. If Borrower existed in Q2 2019, what were
Borrower’s expenses in Q2 2019?
Seasonal borrowers that provided
expenses in Q3 2020 for question 3.A
must provide expenses in Q3 2019.
C. If Borrower did not exist in Q2 2019, what
were Borrower’s expenses in Q1 2020?
Seasonal borrowers that provided
expenses in Q3 2020 for question 3.A
must provide expenses in Q3 2019.
SBA Form 3510 (10/2020)
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$
Select
$
Select
$
Select
$
Select
$
Select
$
Select
$
Select
$
Select
4.
5.
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 4.A is YES, which state or
local authority issued the shutdown order?
C. If the answer to 4.A is YES, provide
Start
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
YES
its operations by a state or local authority
due to COVID-19?
B. If the answer to 5.A is YES, provide start Start
and end dates of the order to alter
its operations (if ongoing, write
“present” under “End”).
NO
Select
Select
End
Select
NO
Select
End
Select
C. If the answer to 5.A is YES, describe how
Borrower’s operations were altered [1,000 character max].
Select
6.
D. If the answer to 5.A is YES, what were
Borrower’s approximate additional cash
$
outlays for these mandatory alterations?
A. At any time since March 13, 2020, has
Borrower voluntarily ceased or reduced its
YES
operations due to COVID-19?
B. If the answer to 6.A is YES, provide start Start
and end dates when Borrower
voluntarily ceased or reduced
operations (if ongoing, write
“present” under “End”).
SBA Form 3510 (10/2020)
4
Select
NO
Select
End
Select
C. If the answer to 6.A is YES, please describe
how and why Borrower’s operations were voluntarily
ceased or reduced [1,000-character max].
Select
7.
A. At any time since March 13, 2020, has
Borrower voluntarily altered its operations
YES
due to COVID-19 (other than ceasing or
reducing operations)?
B. If the answer to 7.A is YES, provide start
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).
NO
Select
End
Select
C. If the answer to 7.A is YES, describe how
Borrower’s operations were voluntarily altered [1,000-character max].
Select
8.
9.
D. If the answer to 7.A is YES, what were
Borrower’s approximate 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
improvement projects not due to COVID19?
B. If the answer to 8.A is YES, what were
Borrower’s approximate cash outlays for
those projects?
What is Borrower’s primary six-digit NAICS
code?
SBA Form 3510 (10/2020)
5
$
Select
YES
$
NO
Select
Select
Select
10.
Optional – provide additional comments on any question in this
Non-Profit Activity Assessment section [1,000-character max]:
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, savings, and temporary cash
investments? Provide supporting
documentation.
2.
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 2.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.
3.
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 3.A is YES, how many
employees?
C. If the answer to 3.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
3.B? Provide supporting documentation.
4.
A. Are there any restrictions on Borrower
using net income or cash, savings, and
temporary cash investments for payroll and
other costs such as mortgage interest, rent,
and utilities payments?
SBA Form 3510 (10/2020)
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Confidential
$
Select
YES
NO
$
Select
Select
YES
NO
Select
Select
$
Select
YES
NO
Select
B. If the answer to 4.A is YES, describe those
restrictions [1,000-character max].
Select
5.
A. Does Borrower, directly or through a
related organization (as defined in IRS
Form 990 Instructions), hold assets in any
endowment funds (as defined in IRS Form
990 Instructions)?
B. If the answer to 5.A is YES, detail below
the types of endowment funds (including
donor-restricted endowments, quasiendowments, or similar) and the value of
the assets held in each endowment as of the
last day of the calendar quarter immediately
before the date of Borrower’s PPP loan
application. Provide supporting
documentation.
Endowment A (type):
Endowment B (type):
Endowment C (type):
Endowment D (type):
C. If the answer to 5.A is YES, describe any
restrictions that apply to the use of the
endowment assets for payroll and other
costs such as mortgage interest, rent, and
utilities payments [1,000-character max].
YES
NO
Select
Select
Select
Select
Select
$
$
$
$
Select
6.
7.
As of the last day of the calendar quarter
immediately before the date of Borrower’s PPP
loan application, what was the value of
Borrower’s non-cash investments (such as
equity, bond, and real estate holdings)?
A. Is Borrower a school, college, or
university?
B. If the answer to 7.A is YES, what was
Borrower’s median tuition paid per student
for the 2019-2020 academic year?
SBA Form 3510 (10/2020)
7
$
Select
YES
$
NO
Select
Select
8.
9.
10.
C. If the answer to 7.A is YES, did Borrower
offer additional financial assistance to
students for the 2019-2020 academic year
due to COVID-19?
D. If the answer to 7.A is YES, did Borrower’s
revenues from tuition decrease for the
2019-2020 academic year due to COVID19 relative to the 2018-2019 academic
year?
E. If the answer to 7.D is YES, what was the
amount of the decline in revenue from
tuition due to COVID-19?
A. Does Borrower provide health care
services?
B. If the answer to 8.A is YES, provide
answers for 8.B.i and either 8.B.ii or
8.B.iii:
i. What was Borrower’s program service
revenue related to patient care in Q2
2020?
Seasonal borrowers may enter
revenue in Q3 2020 instead of Q2
2020.
ii. If Borrower existed in Q2 2019, what
was Borrower’s program service
revenue related to patient care in Q2
2019?
Seasonal borrowers that entered
revenue in Q3 2020 for question
8.B.i must enter revenue in Q3
2019.
iii. If Borrower did not exist in Q2 2019,
what was Borrower’s program service
revenue related to patient care in Q1
2020?
Seasonal borrowers that entered
revenue in Q3 2020 for question
8.B.i must enter revenue in Q3
2019.
C. If the answer to 8.A is YES, did Borrower
offer a discount on its patient care services
due to COVID-19?
If the answers to 7.A and 8.A are NO, did
Borrower offer a discount on its services due to
COVID-19?
A. Did Borrower directly receive any funds
from any CARES Act program other than
PPP, excluding tax benefits?
B. If the answer to 10.A is YES, please
provide funding amount:
SBA Form 3510 (10/2020)
8
YES
NO
Select
YES
NO
Select
$
Select
YES
NO
Select
$
$
Select
$
$
Select
Select
YES
NO
Select
YES
NO
Select
YES
NO
Select
Select
C. If the answer to 10.A is YES, please provide the program name
or describe the funding source [1,000-character max].
Select
11.
Optional – provide additional comments on any question in this
Liquidity Assessment section[1,000-character max].
Select
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
SBA Form 3510 (10/2020)
9
| File Type | application/pdf |
| File Modified | 2020-11-30 |
| File Created | 2020-10-16 |