Download:
pdf |
pdfApply for a SBA Disaster Loan
as a Homeowner or Renter
OMB No. 3245-0018
Expiration Date: 00/00/00
Use this form to apply for a low-interest, long-term loan from the SBA
for physical damage caused by a declared disaster.
Information to prepare
In order to fill out this application completely,
it may be helpful to collect the following items:
•
Your most recent federal tax return
•
Information about the insurance policies on your home, and personal details for
yourself and any Joint Borrower that you want to include in this application
•
You will also need what is called a disaster number, which helps the government
identify the exact occurrence. You can find this at sba.gov/disaster
Disaster declaration
1
Which disaster event affected you?
To qualify for a disaster loan from SBA, your
home needs to be affected by a federallydeclared disaster. These disasters have a
five-digit Disaster Number following the state
abbreviation.
DISASTER NUMBER
e.g. TX - 01234
This number can be found at sba.gov/disaster
or at a Disaster Recovery Center.
2
Have you applied for help from the
Federal Emergency Management
Agency (FEMA)?
Yes, I have applied for help from FEMA
No, I have not applied for help from FEMA
Please note that this is not always available.
Please confirm with your local Disaster
Recovery Center or online at sba.gov/disaster
2a If yes, what is your FEMA
registration number?
This is a 9-digit number
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Where it’s located
3
What is the address for the home
impacted by this disaster?
Provide the address for the home that was
damaged by the disaster event
ADDRESS LINE 1
ADDRESS LINE 2 (Optional)
STATE
CITY
ZIP CODE
About your home
4
Do you own or rent this property?
I am a renter at this property
I own this property individually
I own this property jointly
This property is held by a trust
4a If held by a trust, provide
LEGAL NAME OF TRUST
the name of the trust
Include additional contact
information, if applicable
NAME OF TRUSTEE
EMAIL ADDRESS
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About your home, continued
5
Is this your primary residence?
Yes, this is my primary home
This means you live there for most of the year
and it is the address for your tax return
No, this is not my primary home
5a If no, select from the
following options
If this is not a primary
residence for you, a friend, or a
family member, you may need
to apply as a business
This is a vacation / secondary home
I own the property but a family member or
friend lives at the property
This is a rental / business property
What was damaged
6
What items were damaged
or destroyed?
Select all that apply
If you are the owner of this home, select all that apply:
The structure of my home
My furniture and personal possessions
My car, boat, motorcycle or other personal vehicle
If you are a renter of this home, select all that apply:
The structure of my home (only for ‘lease to own’ renters)
My furniture and personal possessions
My car, boat, motorcycle or other personal vehicle
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Insurance coverage
7
If you have Homeowner’s or Renter’s
Insurance, provide the following
information
NAME OF HOMEOWNER’S OR RENTER’S INSURANCE COMPANY
If not, leave blank.
INSURANCE POLICY NUMBER
If you have received money from your
insurance already, please make note of the
amount in the last box. If you have not but
expect to, be aware that we will need to know
that number later in the process.
8
If you have Flood Insurance, provide
the following information
If not, leave blank.
If you have received money from your
insurance already, please make note of the
amount in the last box.
CURRENT AMOUNT RECEIVED FROM INSURANCE COMPANY, IF ANY
NAME OF FLOOD INSURANCE COMPANY
INSURANCE POLICY NUMBER
CURRENT AMOUNT RECEIVED FROM INSURANCE COMPANY, IF ANY
9
If you have Car Insurance, provide the
following information
If not, leave blank.
If you have received money from your
insurance already, please make note of the
amount in the last box.
NAME OF CAR INSURANCE COMPANY
INSURANCE POLICY NUMBER
CURRENT AMOUNT RECEIVED FROM INSURANCE COMPANY, IF ANY
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Insurance coverage, continued
10 If you have Windstorm Insurance,
NAME OF WINDSTORM INSURANCE COMPANY
provide the following information
If not, leave blank.
If you have received money from your
insurance already, please make note of the
amount in the last box.
INSURANCE POLICY NUMBER
CURRENT AMOUNT RECEIVED FROM INSURANCE COMPANY, IF ANY
11 If you have separate Fire Insurance,
NAME OF FIRE INSURANCE COMPANY
provide the following information
If not, leave blank.
If you have received money from your
insurance already, please make note of the
amount in the last box.
INSURANCE POLICY NUMBER
CURRENT AMOUNT RECEIVED FROM INSURANCE COMPANY, IF ANY
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About you - Primary Applicant
12 What is your legal name?
FIRST NAME
Provide the full name of the primary person
applying for this loan
MIDDLE NAME (Optional)
LAST NAME
13 What is your date of birth?
MONTH
DAY
YEAR
Provide the month, day, and year
14 What is your Social Security Number?
Provide your 9-digit SSN or ITIN
15 Are you married?
Provide your current marital status, which
helps us to confirm your information with the
IRS.
16 Are you a United States citizen?
If your answer is “No,” we may contact you
to learn more about your citizenship status.
You may need to provide a copy of specific
documents like a green card or proof of
permanent residency.
16a
-
-
Yes, I am married
No, I am not married
Yes, I am a United States citizen
No, I am not a United States citizen
If no, please provide a
registration number.
This is the “alien registration
number” provided by US
Citizenship and Immigration.
I do not have a registration number
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How to contact you - Primary Applicant
17 What is your email address?
This is the primary method that we will use to
contact you about your application, and will
be used for logging in to our online portal.
This email may also be used to send you
closing documents for signing on your loan
I do not have an email address
-
18 What is your primary phone number?
We will use this number to contact you for
questions and updates about your application
-
I want to receive updates about my loan via text message
(optional, messaging rates may apply)
18a
-
Do you have an additional phone
number we should use?
-
We will use this number if we cannot
reach your primary phone number
19
What is the best address for
you to receive mail? (optional)
We understand that you may need to move
as part of the process of recovery, and we will
be sending all of our notifications through our
online portal, email, or phone to reach you as
quickly as possible
If you have an additional address where you
would like to receive letters about your loan,
you can provide that here
ADDRESS LINE 1
ADDRESS LINE 2 (Optional)
STATE
CITY
ZIP CODE
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Job and finances - Primary Applicant
20 When the disaster occurred,
Yes, I had a job that provided me income.
did you have an income?
Yes, I was retired and received retirement benefits.
No, I was not working or receiving income before the
disaster event.
21 Before the disaster happened, how
much money did you make each year?
If you file taxes jointly with another person,
you can provide your joint income instead.
Include all reoccurring income such as
employment, self-employment, part-time
work, social security, retirement income,
disability income, child support, alimony, etc.
Do not include one-time or non-recurring
income.
ANNUAL INCOME - SINGLE INDIVIDUAL
$
or
ANNUAL INCOME - HOUSEHOLD / FILING JOINTLY
$
For help in providing this number, you can
check your paystubs, W-2, or 1099.
22 How many people rely
NUMBER OF DEPENDENTS - SINGLE INDIVIDUAL
on your income?
This is usually the number of children and
adults listed as dependents on your tax return.
If you file taxes jointly with another person, you
can provide your joint number of dependents.
or
NUMBER OF DEPENDENTS - HOUSEHOLD / FILING JOINTLY
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Demographic information - Primary Applicant
23a
Are you a veteran,
or the spouse of a veteran?
Optional, Select all that apply
I am a veteran
I am a service-disabled veteran
I am the spouse of a veteran
I am not a veteran
Prefer not to answer
23b
With which gender do you identify?
Male
Optional
Female
Other
Prefer not to answer
23c
What is your ethnicity?
Hispanic or Latino
Optional
Not Hispanic or Latino
Prefer not to answer
23d
What is your race?
American Indian or Alaska Native
Optional, Select all that apply
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Prefer not to answer
Note
Veteran, gender, race, and ethnicity data is collected for program reporting only.
Disclosure is voluntary and has no bearing on the loan decision.
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Joint Applicant
24 Do you want to include a
joint applicant for this loan?
A Joint Applicant can be your
spouse or another person who
will repay the loan with you
Yes, I want to include a joint applicant .......... FILL OUT QUESTIONS 24A - 24S
No, I do not want to include a joint applicant ............. SKIP TO QUESTION 25
About you - Joint Applicant
24a
What is your legal name?
FIRST NAME
Provide the full name of the joint applicant
for this loan
MIDDLE NAME (Optional)
LAST NAME
24b
What is your date of birth?
MONTH
DAY
YEAR
Provide the month, day, and year
24c
What is your Social Security Number?
Provide your 9-digit SSN or ITIN
24d
24e
-
-
Are you married?
Yes, I am married
Provide your current marital status
No, I am not married
Are you a United States citizen?
Yes, I am a United States citizen
If your answer is “No,” we may contact you
to learn more about your citizenship status.
You may need to provide a copy of specific
documents like a green card or proof of
permanent residency.
No, I am not a United States citizen
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How to reach you - Joint Applicant
24f
What is your email address?
This is the primary method that we will use to
contact you about your application, and will
be used for logging in to our online portal.
I do not have an email address
This email may also be used to send you
closing documents for signing on your loan
24g
-
What is your primary phone number?
We will use this number to contact you for
questions and updates about your application
24h
-
I want to receive updates about my loan via text message
(optional, messaging rates may apply)
-
Do you have an additional phone
number we should use?
-
We will use this number if we cannot
reach your primary phone number
24i
What is the best address for
you to receive mail? (optional)
We understand that you may need to move
as part of the process of recovery, and we will
be sending all of our notifications through our
online portal, email, or phone to reach you as
quickly as possible.
If you have an additional address where you
would like to receive letters about your loan,
you can provide that here.
If you use the same mailing address as the
primary applicant, check the box above
Use the same mailing address as the primary applicant
or
ADDRESS LINE 1
ADDRESS LINE 2 (Optional)
STATE
CITY
ZIP CODE
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Job and finances - Joint Applicant
24j
When the disaster occurred, did you
have an income?
Yes, I had a job that provided me income.
Yes, I was retired and received retirement benefits.
No, I was not working or receiving income before the
disaster event.
24k
Before the disaster happened, how
much money did you make each year?
If you file taxes jointly with another person,
you can provide your joint income instead. If
that person is the primary applicant, please
check the button that indicates this.
Include all reoccurring income such as
employment, self-employment, part-time
work, social security, retirement income,
disability income, child support, alimony, etc.
ANNUAL INCOME - SINGLE INDIVIDUAL
$
or
ANNUAL INCOME - HOUSEHOLD / FILING JOINTLY
$
I file taxes jointly with the Primary Applicant
Do not include one-time or non-recurring
income.
For help in providing this number, you can
check your paystubs, W-2, or 1099.
24l
How many people rely
on your income?
This is usually the number of children and
adults listed as dependents on your tax return.
If you file taxes jointly with another person, you
can provide your joint number of dependents.
If your dependents are shared with the joint
applicant and represented there, please check
the button that indicates this rather than
providing a number so they are not double
counted.
NUMBER OF DEPENDENTS - SINGLE INDIVIDUAL
or
NUMBER OF DEPENDENTS - HOUSEHOLD / FILING JOINTLY
My dependents are reflected in the Primary Applicant’s
answer above.
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Demographic information - Joint Applicant
24m
Are you a veteran,
or the spouse of a veteran?
Optional, Select all that apply
I am a veteran
I am a service-disabled veteran
I am the spouse of a veteran
I am not a veteran
Prefer not to answer
24n
With which gender do you identify?
Optional
Male
Female
Other
Prefer not to answer
24o
What is your ethnicity?
Optional
Hispanic or Latino
Not Hispanic or Latino
Prefer not to answer
24p
What is your race?
Optional, Select all that apply
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Prefer not to answer
Note
Veteran, gender, race, and ethnicity data is collected for program reporting only.
Disclosure is voluntary and has no bearing on the loan decision.
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Assets - All Applicants
25 What value did you have in the following assets
before the disaster event occurred?
Include combined assets from all applicants
applying for this loan
25a
Cash, bank accounts,
and marketable securities
$
Includes stocks, bonds, and certificates of
deposit. Do not include retirement accounts
25b
Retirement accounts
This can include IRAs, Keogh, TSP and similar
accounts for retirement savings
25c
Personal property
The pre-disaster value of assets like furniture,
appliances, vehicles, boats, and RVs
25d
Primary residence
The pre-disaster value of your primary home
25e
All other real estate
If you have additional real estate to include as
assets, provide its value and a description
$
$
$
$
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Debts and obligations - All Applicants
26 Primary residence
The monthly payment for the mortgage or
rent on your primary home at the time that the
disaster event occurred
MORTGAGE HOLDER OR LANDLORD’S NAME
MONTHLY PAYMENT / RENT
CURRENT BALANCE
$
26a
Additional mortgage
If you have a second mortgage,
provide that information here.
If you need more space for
additional mortgages, add
additional sheets
26b
Insurance not included
in monthly payment
Provide these amounts only if
they are not already included
in your monthly rent or
mortgage payment
$
ADDITIONAL MORTGAGE HOLDER NAME
MONTHLY PAYMENT
CURRENT BALANCE
$
$
REAL ESTATE TAXES
$
per year
HOMEOWNER’S INSURANCE
$
per year
CONDO / TOWNHOME / HOA / CO-OP FEES
$
27 Other debt
Include any fixed debts that you pay monthly,
such as child support, student loans, and credit
extensions within the last 90 days.
Do not include any medical debt, or any debts
that will last less than 10 months.
per year
NAME OF CREDITOR
MONTHLY PAYMENT
$
CURRENT BALANCE
$
NAME OF CREDITOR
MONTHLY PAYMENT
$
CURRENT BALANCE
$
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Debts and obligations, continued - All Applicants
If you need more space, attach additional sheets
NAME OF CREDITOR
MONTHLY PAYMENT
$
CURRENT BALANCE
$
NAME OF CREDITOR
MONTHLY PAYMENT
$
CURRENT BALANCE
$
NAME OF CREDITOR
MONTHLY PAYMENT
$
CURRENT BALANCE
$
NAME OF CREDITOR
MONTHLY PAYMENT
$
CURRENT BALANCE
$
NAME OF CREDITOR
MONTHLY PAYMENT
$
CURRENT BALANCE
$
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Criminal background and delinquencies - All applicants
28 Is the following true for you or your joint applicant?
28a
28b
28c
28d
28e
28f
28g
Filed bankruptcy in the past 2 years
Yes
No
Have outstanding judgments, tax liens,
or pending lawsuits against them
Yes
No
Presently incarcerated, or on probation or parole
following conviction for a serious criminal offense
Yes
No
In the past year, been convicted of a felony
committed during and in connection with a riot or
civil disorder or other declared disaster
Yes
No
Ever been engaged in the production or
distribution of a product or service that has been
determined obscene by a court of competent
jurisdiction
Yes
No
Currently more than 60 days late on
paying any child support obligations
Yes
No
Currently suspended or debarred from
contracting with the Federal government
or receiving Federal grants or loans
Yes
No
If you answered “Yes” to any of the questions above, use this space to provide dates
and details about each occurrence. If you need more space, attach additional sheets.
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Paid Agent Information
29 Did you pay anyone to support you in
completing this application?
This could be an accountant, packager, or
attorney that worked for a fee.
If yes, provide their name, company, and any
fee charged or agreed upon for their services
AGENT FULL NAME
AGENT COMPANY (If applicable)
ADDRESS LINE 1
ADDRESS LINE 2 (Optional)
STATE
CITY
ZIP CODE
FEE FOR SERVICES
$
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E-SIGN Disclosure and Consent
30 Do you consent to using electronic signatures and electronic communications?
While you are currently filling out a paper form, there may come a time or opportunity where you would
like to receive or sign documents electronically. By checking this consent box, you give us permission
to communicate with you electronically (including billing notifications). In addition, this consent gives us
permission to use your electronic signature for any future documents.
Please read the following information carefully. By checking “I Agree”, you are agreeing that you have reviewed this information and consent to
conduct business with the U.S. Small Business Administration using Electronic Communications and using an electronic signature instead of a
written signature. Communications provided to you in electronic format will be considered to be “in writing” in accordance with the Electronic
Signatures in Global and National Commerce Act.
In this document: “SBA” means the U.S. Small Business Administration; “You” and “your” means the signatory authorized to enter this agreement;
“Communication” or “Electronic Communication” means each disclosure, contract, agreement, statement, record, document, invoice, or other
information that SBA provides to you or that you submit to SBA that may be required by law; and, “Loan” or “transaction” means the SBA Disaster
Loan to which you are applying.
Consent to Use Electronic Signatures: You consent to using electronic signatures for all documents, contracts, agreements, or disclosures
related to this loan. You agree that your use of any device, means, or action to provide your electronic signature constitutes your acceptance and
agreement to the terms and conditions of each document as if actually signed by you in writing. You also agree that no certification authority
or other third party verification is necessary to validate your electronic signature, and that the lack of such certification or third party verification
will not in any way affect the enforceability of your electronic signature. You are confirming that you are the party authorized to enter into this
agreement. You further agree that each use of your electronic signature constitutes your agreement to be bound by the terms and conditions of
each document.
Consent to Electronic Communications: You consent to use and receipt of Communications in electronic format. This consent covers all
Communications related to this transaction. Your consent remains in effect unless and until it is withdrawn. Note that SBA may nevertheless
provide you with some Communications in written, signed, or nonelectronic form.
Withdrawing Consent: You may withdraw your consent to Electronic Communications at any time by opting out in the Loan Application Portal
or by sending your request in writing to [email protected].
This withdrawal will become effective within a reasonable period of time to process your withdrawal. Withdrawal does not apply to any
Electronic Communications provided or made available to you prior to the effectiveness of the withdrawal.
There are no conditions, consequences, or fees associated with withdrawing your consent.
Your Right to Receive Paper Copies: You may print a paper copy of any Electronic Communication, or request a copy by contacting the SBA
Disaster Customer Service Center at [email protected] or 1-800-659-2955. There is no fee for requesting a paper copy of an
Electronic Communication.
Hardware and Software Requirements: To access, view, and retain Electronic Communications, you must have:
•
A connection to the Internet;
•
A supported Internet Browser;
•
Software that is capable of receiving, accessing, and
displaying Electronic Communications from SBA,
whether presented online, in email, or in PDF form;
•
A printer, hard drive, or other storage device
if you wish to print or download and save Electronic
Communications; and,
•
A device and operating system that supports the above.
Changes to Hardware and Software Requirements: If SBA’s hardware and/or software requirements change, and that change would create a
material risk that you would not be able to access or retain your Electronic Communications, SBA will give you notice of the revised hardware or
software requirements, including a reminder of your right to withdraw consent to Electronic Communications.
You Must Keep Your Contact Information Current: You are responsible for maintaining current contact information, such as email addresses and
cell phone number, with SBA to continue receiving Electronic Communications. You may update your contact information by contacting the SBA
Disaster Customer Service Center at [email protected] or 1-800-659-2955.
Yes, I consent to electronic signatures and electronic communications
No, I do not consent to electronic signatures and electronic communications
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Consent and signatures
31 Do you agree to the following terms?
If you agree, sign below with your signature and today’s date.
If you have a co-applicant, they are required to sign and date as well.
I/We authorize my/our insurance company, bank, financial institution, or other creditors to release to SBA all records and information necessary
to process this application.
If my/our loan is approved, additional information may be required prior to loan closing. I/We will be advised in writing what information will be
required to obtain my/our loan funds.
I/We hereby authorize the SBA to verify my/our past and present employment information and salary history as needed to process and service a
disaster loan.
I/We authorize SBA, as required by the Privacy Act, to release any information collected in connection with this application to Federal, state,
local, tribal or nonprofit organizations (e.g. Red Cross Salvation Army, Mennonite Disaster Services, SBA Resource Partners) for the purpose of
assisting me with my/our SBA application, evaluating eligibility for additional assistance, or notifying me of the availability of such assistance.
I/We will not exclude from participating in or deny the benefits of, or otherwise subject to discrimination under any program or activity for which
I/we receive Federal financial assistance from SBA, any person on grounds of age, color, handicap, marital status, national origin, race, religion,
or sex.
I/We will report to the SBA Office of the Inspector General, Washington, DC 20416, any Federal employee who offers, in return for compensation
of any kind, to help get this loan approved. I/We have not paid anyone connected with the Federal government for help in getting this loan.
If my loan is approved, I may be eligible for mitigation – additional funds up to 20 percent of the total SBA verified physical losses - to safeguard
my property from future damages. I am not obligated to accept these additional funds. If I do accept these additional funds for mitigation, I
agree to only use them for mitigation purposes as specified in my loan agreement.
I have received and read a copy of the “STATEMENTS REQUIRED BY LAWS AND EXECUTIVE ORDERS” which was attached to this application.
CERTIFICATION AS TO TRUTHFUL INFORMATION: By signing this application, you certify that all information in your application and submitted
with your application is true and correct to the best of your knowledge, and that you will submit truthful information in the future.
WARNING: Whoever wrongfully misapplies the proceeds of an SBA disaster loan shall be civilly liable to the Administrator in an amount equal to
one-and-one half times the original principal amount of the loan under 15 U.S.C. 636(b).
Any false statement or misrepresentation to SBA may result in criminal, civil or administrative sanctions including, but not limited to:
1.
Fines and imprisonment, or both, under 15 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.
SIGNATURE OF PRIMARY APPLICANT OR DESIGNATED TRUSTEE
SIGNATURE OF JOINT APPLICANT
MONTH
MONTH
DAY
YEAR
DAY
YEAR
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Additional information about this form
This form is for use by individual homeowners or renters to apply for an SBA physical disaster loan as applicable.
The requested information is required to obtain a benefit under our SBA Disaster Home Loan Program and helps
the Agency determine whether the applicant is eligible for a disaster loan and has repayment ability.
If you have questions about this application and how to submit it or problems providing the required information,
please contact our Customer Service Center at 1-800-659-2955 or [email protected]. If more
space is needed for any section of this application, please attach additional sheets.
You may submit the form:
• Online on SBA’s secure website www.sba.gov
• In-person at a disaster recovery center
• By mail:
U.S. Small Business Administration, Processing and Disbursement
14925 Kingsport Rd. Ft. Worth, TX 76155-2243
SBA will contact you by phone or email to discuss your loan request.
Filing requirements
Required for all loan applications:
•
Complete and sign this application form (SBA Form 5C)
•
Complete and sign the Tax Information Authorization (IRS Form 4506C) enclosed with this application. This
income information, obtained from the IRS, will help us determine your repayment ability
While not necessary to accept your application, you may be required to supply the following
information to process the application. If requested, please provide within 7 days of the
information request:
•
If any applicant has changed employment within the past two years, provide a copy of a current (within 1
month of the application date) pay stub for all applicants
•
If we need additional income information, you may be asked to provide copies of your Federal income tax
returns, including all schedules
If SBA approves your loan, we may require the following items before loan closing.
We will advise you, in writing, of the documents we need.
•
If you own your residence, a COMPLETE legible copy of the deed, including the legal description of the
property
•
If the damaged property is your primary residence, proof of residency at the damaged address
•
If you had damage to a manufactured home, a copy of the title. If you own the lot where the home is located,
a COMPLETE legible copy of the deed, including the legal description of the property
•
If you have damage to an automobile or other vehicle, proof of ownership (a copy of the registration, title,
bill of sale, etc.)
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Statements required by Laws and Executive Orders
Note: Please read, detach, and keep for your records
To comply with legislation passed by the Congress and Executive Orders issued by the President, Federal
executive agencies, including the Small Business Administration (SBA), must notify you of certain information. You
can find the regulations and policies implementing these laws and Executive Orders in Title 13, Code of Federal
Regulations (CFR), Chapter 1, or our Standard Operating Procedures (SOPs). In order to provide the required
notices, the following is a brief summary of the various laws and Executive Orders that affect SBA’s Disaster Loan
Programs.
The Small Business Act, Public Law (PL) 85-536 authorizes the Small Business Administration (SBA) to collect
the information on this form. Your disclosure of the information is voluntary. However, failure to disclose certain
information may delay the processing of your eligibility or denial. The SBA will not deny eligibility if you refuse to
disclose your Social Security Number. This information is collected to participate in a loan or grant to determine
eligibility for a SBA program. The information collected may be released to appropriate Federal, State and Local
Agencies, credit bureaus and Servicing agents when relevant to civil, criminal, or regulatory proceedings or to
enforce regulations by manual or automated verification procedures.
STATEMENT REGARDING LOBBYING (APPLICABLE ONLY TO LOANS EXCEEDING $150,000)
If any funds have been paid or will be paid to any person for influencing or attempting to influence an officer
or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a
Member of Congress in connection with this commitment providing for the United States to provide a loan, the
Applicant(s) will complete and submit Standard Form LLL, “Disclosure of Lobbying Activities,” in accordance with
13 CFR Part 146. Applicant(s) acknowledges submission of this disclosure is a prerequisite for making or entering
into this transaction imposed by Section 1352, Title 31, U.S. Code, and that any person who fails to file or amend
a declaration required to be filed or amended will be subject to a civil penalty in the amounts set forth in 13 CFR
§146.400.
FREEDOM OF INFORMATION ACT (5 U.S.C. 552)
This law provides, with some exceptions, that we must make records or portions of records contained in our files
available to persons requesting them. This generally includes aggregate statistical information on our disaster
loan programs and other information such as names of borrowers (and their officers, directors, stockholders or
partners), loan amounts at maturity, the collateral pledged, and the general purpose of loans. We do not routinely
make available to third parties your proprietary data without first doing pre-notification, as required by Executive
Order #12600, or confidential business information, information that would cause competitive harm, or information
that would constitute a clearly unwarranted invasion of personal privacy.
Send a request under this Act to the SBA office maintaining the records requested and identify it as a Freedom of
Information Act (FOIA) request. The request must describe the specific records you want. For information about
the FOIA, contact the Chief, FOI/PA Office, 409 3rd Street, SW, Suite 5900, Washington, DC 20416, or by e-mail at
[email protected].
PRIVACY ACT (5 U.S.C. 552a)
Anyone can request to see or get copies of any personal information that we have in your file. Any personal
information in your file that is retrieved by individual identifiers, such as name or social security number is
protected by the Privacy Act, which means requests for information about you may be denied unless we have your
written permission to release the information to the requestor or unless the information is subject to disclosure
under the Freedom of Information Act. The Agreements and Certifications section of this form contains written
permission for us to disclose the information resulting from this collection to state, local or private disaster relief
services.
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Statements required by Laws and Executive Orders, continued
The Privacy Act authorizes SBA to make certain “routine uses” of information protected by that Act. One such
routine use for SBA’s loan system of records is that when this information indicates a violation or potential violation
of law, whether civil, criminal, or administrative in nature, SBA may refer it 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 of personal information is to assist in obtaining
credit bureau reports on Disaster Loan Applicants and guarantors for purposes of originating, servicing, and
liquidating Disaster loans. See, 86 FR 64979 (and as amended from time to time) for additional background and
other routine uses.
Under the provisions of the Privacy Act, you are not required to provide social security numbers. (see exception
under Debt Collection Act below) We use social security numbers to distinguish between people with a similar or
the same name for credit decisions and for debt collection purposes. Failure to provide this number may not affect
any right, benefit or privilege to which you are entitled by law, but having the number makes it easier for us to
more accurately identify to whom adverse credit information applies and to keep accurate loan records.
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 foia@sba.
gov for information about the Agency’s procedures relating to the Privacy Act and the Freedom of Information Act.
DEBT COLLECTION ACT OF 1982; DEFICIT REDUCTION ACT OF 1984; DEBT COLLECTION IMPROVEMENT ACT
OF 1996 & other titles (31 U.S.C. 3701 et seq.)
These laws require us to aggressively collect any delinquent loan payments and to require you to give your
taxpayer identification number to us when you apply for a loan. If you receive a loan and do not make payments
when they become due, we may take one or more of the following actions (this list may not be exhaustive):
•
Report the delinquency to credit reporting bureaus.
•
Offset your income tax refunds or other amounts due to you from the Federal Government.
•
Refer the account to a private collection agency or other agency operating a debt collection center.
•
Suspend or debar you from doing business with the Federal Government.
•
Refer your loan to the Department of Justice.
•
Foreclose on collateral or take other actions permitted in the loan instruments.
•
Garnish wages.
•
Sell the debt.
•
Litigate or foreclose.
RIGHT TO FINANCIAL PRIVACY ACT OF 1978 (12 U.S.C. § 3401 et seq.)
This notifies you, as required by the Right to Financial Privacy Act of 1978 (Act), of our right to access financial
records held by financial institutions that were or are doing business with you or your business. This includes
financial institutions participating in loans or loan guarantees.
The law provides that we may access your financial records when considering or administering Government loan
or loan guaranty assistance to you. We must give a financial institution a certificate of our compliance with the Act
when we first request access to your financial records. No other certification is required for later access. Our access
rights continue for the term of any approved loan or loan guaranty. We do not have to give you any additional
notice of our access rights during the term of the loan or loan guaranty.
We may transfer to another Government authority any financial records included in a loan application or about an
approved loan or loan guaranty as necessary to process, service, liquidate, or foreclose a loan or loan guaranty.
We will not permit any transfer of your financial records to another Government authority except as required or
permitted by law.
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Statements required by Laws and Executive Orders, continued
CONSUMER CREDIT PROTECTION ACT (15 U.S.C. 1601 et seq.)
This legislation gives an applicant who is refused credit because of adverse information about the applicant’s
credit, reputation, character or mode of living an opportunity to refute or challenge the accuracy of such reports.
Therefore, if we decline your loan in whole or in part because of adverse information in a credit report, you will
be given the name and address of the reporting agency so you can seek to have that agency correct its report, if
inaccurate. If we decline your loan in whole or in part because of adverse information received from a source other
than a credit reporting agency, you will be given information but not the source of the report.
Within 3 days after the consummation of the transaction, any recipient of an SBA loan which is secured in whole
or in part by a lien on the recipient’s residence or household contents may rescind such a loan in accordance with
“Regulation Z” of the Federal Reserve Board.
PLEASE NOTE: The estimated burden for completion of this form, including gathering the information and
completing and reviewing the response, is 1.25 hours. You are not required to respond to this information
collection unless a valid OMB control number is displayed. The number for this collection of information is
3245-0018. 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 3rd
Street, S.W., Washington, DC 20416, and/or SBA Desk Officer, Office of Management and Budget, New Executive
Office Building, Room 10202, Washington, DC 20503.
PLEASE SUBMIT OR RETAIN THE COMPLETED FORM ACCORDING TO THE INSTRUCTIONS ABOVE.
PLEASE DO NOT SEND FORMS TO OMB.
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| File Type | application/pdf |
| File Title | Certification of Vaccination |
| File Modified | 2023-05-16 |
| File Created | 2023-05-01 |