SBA Form 1993 Federal Agency Comment Form

Federal Agency Comment Form

Small Business Administration – Office of the National Ombudsman

OMB Control #3245-0313

PURPOSE: Small business owners may use this form to submit comments on Federal enforcement/compliance actions
that they consider excessive or unfair. The National Ombudsman will use the information when it contacts the
applicable Federal agency for a review of the action. Completion of this form is voluntary; however, failure to submit
the requested information could impact whether SBA’s Office of the National Ombudsman is able to provide you with
assistance

Exp. date 9/30/2022
Case #:

Instructions

1. Complete, sign and date this form. (Signature not required if completed at Office-National-Ombudsman)
2. Provide a brief written statement on the reverse side or a separate sheet of paper regarding the specific
enforcement or compliance action taken against your organization by the federal agency
3. Submit copies of substantiating documentation such as correspondence citation or notice (Note: can
be submitted separately from this form by fax or mail. Make sure to reference your name or
company’s name with this information).
4. If your comments concern the IRS, you must also submit a completed IRS Tax Information Authorization
Form 8821, available at IRS.gov/forms (Can be sent by fax or mail.)
5. Fax, e-mail or send this form and requested information to: (1) Fax: (202) 481-5719; (2) Email:
[email protected]; (3) Address: SBA, Office of National Ombudsman, 409 Third Street, SW,
Washington, DC 20024. Telephone: (202) 205-2417.

Please Print
Organization/Company Name:
Address:
City:

State:

Phone:

Fax:

Contact Name:

Mr.

Zip
E-Mail:

Ms.

Title:

Please indicate your organization type:
Small Business

Not-for-Profit Representing

Small Government (Population of less than 50,000)

Members
Association Representing

Members

List the federal agency with which you are having a problem
Federal Agency Name:
Agency Contact Person:
Agency Office/Division:
Did the federal agency listed above inform you of you right to contact the SBA Office of the National Ombudsman?
Yes

No

If not how did you learn about this Office

Confidentiality/Disclosure

The National Ombudsman is required to keep confidential the identity of any person or small business providing a
comment about an agency’s compliance or enforcement action unless that person or small business provides
consent, or disclosure is determined to be unavoidable. Confidentiality is governed by the Small Business
Regulatory Enforcement Fairness Act 15 U.S.C. 657(b)(2(B) and the Inspector General’s Act, 5 U.S.C. App., §
7(b). You may make a selection below to authorize SBA to share your identity with the federal agency with which
you are having a problem so that agency can investigate your specific problem and offer a response tailored to your
situation. By requesting confidentiality, the federal agency may not have sufficient information to investigate your
specific problem, possibly delaying or preventing any potential resolution of your situation

I request that my identity be shared only with the federal agency(ies) with which I am having a problem
I request that my identity be kept confidential. (Results may be limited.)
Signature:

Date:
Your signature authorizes the SBA Ombudsman to proceed on your behalf.

Pursue all legal options you believe are in your company’s best interest.
This process is not a substitute for legal action.
SBA FORM 1993 (9-19) Previous Editions Obsolete
PLEASE NOTE: The estimated burden for completing this form is 45 minutes. You are not required to
respond to this information collection if a valid OMB approval number is not displayed. If you have any
questions or comments concerning this estimate or other aspects of this information collection, please contact
the U. S. Small Business Administration, Director, Records Management Division, 409 Third Street, SW,
Washington, D.C ., 20416 and/or Office of Management and Budget, SBA Desk Officer, New Executive
Office Building, Rm. 10202, Washington, D.C. 20503. PLEASE DO NOT SEND FORMS TO OMB, as this
will delay action on your request for assistance.

Type or (print) your comments below: