O MB Control No: 3245-0007
Expiration Date: XX/XX/XXX
U.S. SMALL BUSINESS ADMINISTRATION
APPLICATION FOR SURETY BOND GUARANTEE ASSISTANCE
TO BE COMPLETED BY SMALL BUSINESS AND SUBMITTED TO THE SURETY AGENT OF CHOICE
(See page 6 for instructions)
PART I: BUSINESS INFORMATION (Complete this section for initial application and to update information previously submitted.) |
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Street: Click or tap here to enter text. City: Click or tap here to enter text. |
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☐Proprietorship ☐Partnership ☐Corporation ☐Joint Venture ☐ LLC Type of Corp: Click or tap here to enter text. |
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☐Yes ☐No (If yes, attach 3 or 5 years of tax returns) |
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☐ is an SBA 8(a) Certified Contractor according to 13 CFR Chapter 1, Part 124. ☐ is an SBA Certified HUB Zone Contractor according to 13 CFR Chapter 1, Part 126. ☐ is a Veteran Owned Small Business according to 13 CFR Chapter 1, Part 115. ☐ is a Service-Disabled Veteran Owned Small Business according to 13 CFR Chapter 1, Part 115. ☐ is a Federally recognized Tribal Entity or Native American small business according to 13 CFR Chapter 1, Part 124. ☐ is a socially and economically disadvantaged small business according to 13 CFR Part 124.103 and 124.104. |
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☐ has received SBA Surety Bond Guarantee Assistance under another business name. If so, Business Name: Click or tap here to enter text. Tax ID or SSN: Click or tap here to enter text. ☐ has defaulted on any previous surety bonds (SBA or other) under a different EIN/TIN/SSN If so, Business Name: Click or tap here to enter text.Tax ID or SSN: Click or tap here to enter text. ☐ has ever failed to complete a job, bonded or non-bonded projects. If so, include pertinent information in comments section. Click or tap here to enter text. |
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The following data is collected for administrative purposes only. It has no bearing on the applicants guarantee percentage or credit decision. ☐ is an SBA Certified Women-Owned small business ☐ is an SBA Certified Economically Disadvantaged Women-Owned small business |
PART II: MANAGEMENT INFORMATION (Complete this section for initial application and to update information previously submitted.) |
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MANAGEMENT (Proprietor, partners, officers, directors, all holders of outstanding stock/equity – 100% of ownership must be shown): Use separate sheet if necessary. |
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☐ Male ☐ Female |
☐ Yes ☐ No |
☐ Yes ☐ No |
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☐ Black / African American ☐ Native Hawaiian / Pacific Islander ☐ White |
☐ Hispanic or Latino ☐Not Hispanic or Latino |
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☐ Male ☐ Female |
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☐ Black / African American ☐ Native Hawaiian / Pacific Islander ☐ White |
☐ Hispanic or Latino ☐Not Hispanic or Latino |
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☐ Male ☐ Female |
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☐ Black / African American ☐ Native Hawaiian / Pacific Islander ☐ White |
☐ Hispanic or Latino ☐Not Hispanic or Latino |
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*This data is collected for statistical purposes only. It has no bearing on the credit decision. Disclosure is voluntary. One or more boxes for race may be selected. |
PART III: CONTRACT INFORMATION (Complete this section for each bid and final bond guarantee.) |
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☐ Bid ☐ Payment ☐ Performance ☐ Payment and Performance ☐ Performance, Stand-Alone Maintenance |
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☐ Construction ☐ Service ☐ Supply ☐ Other Click or tap here to enter text. |
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Dollar Amount: Click or tap here to enter text. |
Similar to previous work: ☐ Yes ☐ No Pertains to an 8(a) contract: ☐ Yes ☐ No |
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PART IV: AGREEMENTS, CERTIFICATIONS AND COMMENTS (Complete this section for Initial Applications and Each Bid and Final Bond Guarantee.) |
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Agreements: In consideration of assistance from the SBA, I agree to comply with the nondiscrimination requirements of Title 13, Code of Federal Regulations, Part 113 and Executive Order 11246. I agree to pay the applicable contractor fee for a final (payment or performance) bond. Certification: On behalf of the applicant business, I certify:
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Comments:
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I understand that knowingly making a false statement or submitting false information is a violation of Federal law and could result in criminal prosecution or civil penalties under 18 U.S.C. §§ 287, 371, 1001, 15 U.S.C. § 645, or 31 U.S.C. § 3729 |
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Principal’s Signature (Applicant):Click or tap here to enter text. |
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Title:Click or tap here to enter text. |
Date:Click or tap here to enter text. |
SBG Number:Click or tap here to enter text. |
Part V: INDIVIDUAL CERTIFICATIONS ON CITIZENSHIP AND CHARACTER AND OTHER MATTERS |
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(Complete this paragraph as follows: (a) with the first Application submitted on or after October 1 of each year; (b) with any Application that is submitted after any changes in the ownership of the small business; or (c) if any of the answers to questions 1-5 below change with respect to any individual who previously answered these questions in connection with a prior Application, that individual must complete this section for any subsequent Application) Each Proprietor, each General Partner, each Guarantor, and each Limited Partner, Stockholder, or other equity holder owning 20% or more of the small business must answer the questions below. The person signing on behalf of the business must also sign in his or her individual capacity. In addition, if spouses collectively own 20% or more of the small business, each spouse must also sign. Initial each response where indicated to confirm your response to the question. Attach a copy of Part V. if needed for additional individuals.
☐ Yes ☐ No Individual #1 Initials: Click or tap here to enter text. ☐ Yes ☐ No Individual #2 Initials: Click or tap here to enter text. ☐ Yes ☐ No Individual #3 Initials: Click or tap here to enter text. If “No”, are you a Lawful Permanent Resident alien? ☐ Yes ☐ No Individual #1 Initials: Click or tap here to enter text. If “Yes”, provide Alien Registration Number:Click or tap here to enter text. If “No”, country of citizenship: Click or tap here to enter text. ☐ Yes ☐ No Individual #2 Initials: Click or tap here to enter text. If “Yes”, provide Alien Registration Number: Click or tap here to enter text. If “No”, country of citizenship: Click or tap here to enter text. ☐ Yes ☐ No Individual #2 Initials: Click or tap here to enter text. If “Yes”, provide Alien Registration Number: Click or tap here to enter text. If “No”, country of citizenship: Click or tap here to enter text.
☐ Yes ☐ No Individual #1 Initials: Click or tap here to enter text. ☐ Yes ☐ No Individual #2 Initials: Click or tap here to enter text. ☐ Yes ☐ No Individual #3 Initials: Click or tap here to enter text.
☐ Yes ☐ No Individual #1 Initials: Click or tap here to enter text. ☐ Yes ☐ No Individual #2 Initials: Click or tap here to enter text. ☐ Yes ☐ No Individual #3 Initials: Click or tap here to enter text.
☐ Yes ☐ No Individual #1 Initials: Click or tap here to enter text. ☐ Yes ☐ No Individual #2 Initials: Click or tap here to enter text. ☐ Yes ☐ No Individual #3 Initials: Click or tap here to enter text. If you answer “Yes” to questions 3 or 4, you must furnish details on a separate sheet, including dates, location, fines, sentences, level of charge (whether misdemeanor or felony), dates of parole/probation, unpaid fines or penalties, name(s) under which charged, and any other pertinent information. If you answer “Yes” to question 4 and are currently on parole or probation, the applicant is not eligible for SBA assistance.
☐ Yes ☐ No Individual #1 Initials: Click or tap here to enter text. ☐ Yes ☐ No Individual #2 Initials: Click or tap here to enter text. ☐ Yes ☐ No Individual #3 Initials: Click or tap here to enter text. By my signature, I certify that I have received and read a copy of the “STATEMENTS REQUIRED BY LAW AND EXECUTIVE ORDER” (Statements), which is attached to this Application, and I agree to comply, whenever applicable, with the requirements in the Statement. I also certify that I have reviewed the information in this Application and that all of the information that I have provided in this Application and in all supporting documents and forms submitted with this Application is true, correct, and complete to the best of my knowledge. I understand that knowingly making a false statement or submitting false information is a violation of Federal law and could result in criminal prosecution or civil penalties under 18 U.S.C. § 287, 371, 1001, 15 U.S.C. § 645, or 31 U.S.C. § 3729. In addition, I authorize the SBA to request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for programs authorized by the Small Business Investment Act, as amended. I also authorize any agent, broker, Surety Company, financial institution, or other party to release to SBA any information in its possession relating to my credit, financial or work experience in order that SBA may evaluate this application for bond guarantee assistance. |
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Individual #1 Signature: Click or tap here to enter text. Title: Click or tap here to enter text. |
Date: Click or tap here to enter text. |
Individual #2 Signature: Click or tap here to enter text. Title: Click or tap here to enter text. |
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Individual #3 Signature: Click or tap here to enter text. Title: Click or tap here to enter text. |
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SUBMISSION INSTRUCTIONS:
This form is used by small businesses to apply for surety bond guarantee assistance. The information collected is used by SBA and PSB Sureties to determine whether the application for assistance should be approved or declined.
Applicant must contact a surety agency which participates in SBA’s Surety Bond Guarantee (SBG) Program. A list of participating surety agencies and instructions on how to apply for SBG assistance are on the Office of Surety Guarantees website at https://www.sba.gov/funding-programs/surety-bonds#paragraph-13.
Upon completion of its underwriting, surety forwards all required documents through the Capital Access Financial System. If the form is prepared electronically, the completed form must be printed, signed and then uploaded into CAFS located at https://www.sba.gov/partners/surety-bond-partners-agents/operate-surety-partner-or-agent. If CAFS is unavailable, a paper copy of the form is available on the Office of Surety Guarantees (OSG) website at https://www.sba.gov/document/sba-form-994-application-surety-bond-guarantee-assistance where it may be printed, completed, signed and mailed to the OSG office at 409 3rd St., S.W. Suite 8600 Washington, D.C. 20416.
SBA staff reviews the application, makes a final determination, and notifies surety of its decision. SBA returns the signed Guarantee Agreement to the surety.
If the application is for a final (performance and/or payment) bond, SBA’s approval is contingent upon the remittance to SBA of the guarantee fee owed by the contractor
If any adverse information develops subsequent to SBA’s approval of the bond guarantee, surety may decline to issue the bonds.
PLEASE NOTE: The estimated burden for completing this form, including time for reviewing instructions, gathering the information needed, and completing and reviewing your responses, is approximately 10 minutes. You are not required to respond to any collection of information unless it displays a currently valid OMB Control Number (3245-0007). If you wish to submit comments on the estimated completion time or any other aspect of this collection of information, direct these comments to: U.S. Small Business Administration, Director, Records Management Division, 409 3rd St., S.W., Washington, D.C. 20416 and/or Desk Officer for the Small Business Administration, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503. PLEASE DO NOT SEND COMPLETED FORMS TO OMB.
PLEASE READ, DETACH, AND RETAIN FOR YOUR RECORDS
STATEMENTS REQUIRED BY LAW AND EXECUTIVE ORDER
This application, and any assistance provided pursuant to this application, is subject to the following laws, regulations, and Executive Orders:
Freedom of Information Act (5 U.S.C. 552)
This law provides, with some exceptions, that SBA must provide information contained in agency files and records to a person requesting it. Information about approved bond guarantees that will be automatically released includes, among other things, statistics on the Surety Bond Guarantee (SBG) programs and other information such as the names of small businesses (and their officers, directors, stockholders or partners) and the amount of the bond guarantees. Proprietary data on an applicant 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.
Privacy Act (5 U.S.C. 552a) and Debt Collection Improvement Act (31 U.S.C. 7701)
Authorities and Purpose for Collecting Information: SBA is collecting the information on this form, including social security numbers and other personal information, to make a character and credit eligibility decision in connection with you or your company’s application for SBA assistance. SBA may also use social security numbers for the purpose of collecting and reporting on any delinquent fees or other amounts owed SBA.
Under the provisions of 31 U.S.C. 7701, the applicant business and any indemnitor of the bond are required to provide their social security numbers, or other taxpayer identification numbers, in order to do business with SBA. Failure to provide this information would affect your ability to obtain an SBA guaranteed bond. For other individuals signing this application, the submission of the social security number is voluntary and failure to provide your social security number may not affect any right, benefit or privilege to which you are entitled. However, in evaluating whether the applicant satisfies the criteria for a bond guarantee under section 411 of the Small Business Investment Act, 15 USC 694b, SBA considers whether the applicant and each owner of 20% or more of its equity, and each of its officer, directors, or general partners, possesses good character. In making this determination, SBA considers the person’s integrity, candor, and criminal history if any. SBA is authorized, through section 308(f) of the Small Business Investment Act, to verify your criminal history, or lack thereof, pursuant to section 7(a)(1)(B) of the Small Business Act, 15 USC § 636(a)(1)(B). In addition, for all forms of assistance, SBA is authorized to make all investigations necessary to ensure that a person has not engaged in acts that violate or will violate the Small Business Investment Act, see 15 USC Section 687b(a). In conducting the criminal background check, SBA also uses your social security number to distinguish you from other individuals with the same or similar name or other personal identifier. This use is permitted under Executive Order 9397.
Routine Uses: Some of the information collected may be checked against criminal history indices of the Federal Bureau of Investigation. When the information collected 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. See, SBA’s Privacy Act System of Records, at 74 Fed. Reg. 14890 (2009) (as amended from time to time) for other published routine uses for the collected information.
Right to Financial Privacy Act of 1978 (12 U.S.C. 3401)
This is notice, as required by the Right of Financial Privacy Act of 1978, of SBA’s access rights to financial records held by financial institutions that are or have been doing business with you or your business. The law provides that SBA shall have a right of access to your financial records in connection with its consideration or administration of assistance to you in the form of a bond guarantee. SBA is required to provide a certificate of its compliance with this Act to a financial institution in connection with its first request for access to your financial records, after which no further certification is required for subsequent access. The law also provides that SBA’s access rights continue for the term of any approved bond agreement. No further notice to you of SBA’s access rights is required during the term of any such agreement.
The law also authorizes SBA to transfer to another Government authority any financial records included in an application for a bond guarantee, or concerning an approved bond guarantee, as necessary to process or service the bond guarantee. No other transfer of your financial records to another Government authority will be permitted by SBA except as required or permitted by law.
Flood Disaster Protection Act (42 U.S.C. 4011)
Under this Act, and its implementing regulations, SBA is prohibited from providing financial assistance in a designated floodplain unless Federal flood insurance is purchased as a condition of the assistance. Failure to maintain the required level of flood insurance makes the applicant ineligible for any future financial assistance from SBA under any program, including disaster assistance.
Executive Orders 11988 and 11990 -- Floodplain Management and Wetland Protection (42 F.R. 26951 and 42 F.R. 26961)
SBA discourages settlement in or development of a floodplain or a wetland. This statement is to notify all applicants for SBA assistance that such actions are hazardous to both life and property and should be avoided. The additional cost of flood preventive construction must be considered in addition to the possible loss of all assets and investments due to a future flood.
Executive Order 11738 – Environmental Protection (38 F.R. 251621)
This Executive Order charges SBA with administering its financial assistance programs in a manner that will result in effective enforcement of the Clean Air Act, the Federal Water Pollution Act and other environmental protection legislation.
Occupational Safety and Health Act (15 U.S.C. 651 et seq.)
This legislation authorizes the Occupational Safety and Health Administration in the Department of Labor to require businesses to modify facilities and procedures to protect employees or pay penalty fees. In some instances, the business can be forced to cease operations or be prevented from starting operations in a new facility. Therefore, in some instances, SBA may require additional information from an applicant to determine whether the business will be in compliance with OSHA regulations and allowed to operate its facility after the bond guarantee agreement is approved. Signing this form as an applicant is a certification that the applicant has determined which OSHA requirements, if any, apply to the applicant’s business and the applicant to the best of its knowledge is in compliance.
Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4821 et seq.)
Businesses that receive surety bond guarantee assistance from SBA for a contract to construct or rehabilitate a residential structure are prohibited from using lead-based paint (as defined in SBA regulations) on all interior surfaces, whether accessible or not, and exterior surfaces, such as stairs, decks, porches, railings, windows and doors, which are readily accessible to children under 7 years of age. A “residential structure” is any home, apartment, hotel, motel, orphanage, boarding school, dormitory, day care center, extended care facility, college or other school housing, hospital, group practice or community facility and all other residential or institutional structures where persons reside.
Civil Rights Legislation
All businesses receiving SBA 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 113 and 117 of SBA Regulations. This includes making the business’ goods and services available to handicapped clients or customers. All businesses receiving assistance will be required to display the “Equal Employment Opportunity Poster” prescribed by SBA.
Debt Collection Act of 1982 and Debt Collection Improvement Act of 1996 (5 U.S.C. 5514 note and 31 U.S.C. 3701 et seq.)
These laws require SBA to aggressively collect fee payments (or any other amount due to SBA) that become delinquent. If you receive a bond guarantee, and do not pay the related fee (or any other amount due to SBA), SBA may take one or more of the following actions:
Report the status of your payment delinquency to credit bureaus
Hire a collection agency to collect your fee
Offset your income tax refund or other amounts due to you from the Federal Government
Suspend or debar you or your company from doing business with the Federal Government
Refer your delinquent fee (or any other amount due to SBA) to the Department of Justice or other attorney for litigation
Foreclose on collateral or take other action permitted
Executive Order 12549 as amended by E.O. 12689, Debarment and Suspension (2 CFR 180, adopted by reference in 2 CFR Part 2700 (SBA Debarment Regulations))
By submission of this application, you certify and acknowledge that neither you nor any Principals have within the past three years been: (a) debarred, suspended, declared ineligible from participating in, or voluntarily excluded from participation in a transaction by any Federal department or 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 due and owing to the U.S. Government or its agencies or instrumentalities as of the date of execution of this certification. If you are unable to certify and acknowledge (a) through (d), you must obtain and attach a written statement of exception from SBA permitting participation in this surety bond guarantee. You further certify that you have not and will not knowingly enter into any agreement in connection with the goods and/or services purchased with the proceeds of this loan with any individual or entity that has been debarred, suspended, declared ineligible from participating in, or voluntarily excluded from participation in a Transaction. All capitalized terms have the meanings set forth in 2 C.F.R. Part 180.
SBA
Form 994 (9/22) Previous Editions are Obsolete
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