SBA Form 3513 Declaration of Identity Theft

OMB Control Number 3245-0418 Expiration Date: xx/xx/20xx

United States Small Business Administration Declaration of Identity Theft

Complete this form if you need the U.S. Small Business Administration to review an outstanding loan or grant for identity theft. Before beginning, please note that a hand-written signature is required for this declaration, as well as attachments.

Providing the information on this form is voluntary with the exception of the Social Security Number. However, if you do not provide the information, it may be more difficult to assist you in resolving your identity theft issue. For Identity Theft Declarations pertaining to direct SBA physical and economic injury disaster loans, such as COVID Economic Injury Disaster Loans (EIDL), send the completed form via email to: [email protected]. For Identity Theft Declarations pertaining to other programs, including Paycheck Protection Program (PPP) loans, Restaurant Revitalization Awards (RRF), 504 loan program, and other 7(a) loans send the completed form via email to: [email protected].

Section A – Check the box below that applies to the situation you are reporting

I am submitting this Declaration for myself as a sole proprietor/individual or as the authorized representative for a business named .¹

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I am submitting this Declaration on behalf of my minor child (or I am the guardian of the minor child).²

The identity theft victim is deceased, and I am submitting this Declaration as the surviving spouse, Court-Appointed Personal Representative, Executor, or Administrator.³

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The identity theft victim is incapacitated, and I am submitting this Declaration as the Power of Attorney, Court-Appointed Guardian, or Conservator.⁴

Section B – Representative, Conservator, Parent or Guardian contact information⁵

Representative’s Last Name: First Name: Current Street Mailing Address: City: State: ZIP Code:

Telephone Number: Alternate Telephone Number: Email address: _

Section C – Name and contact information of Identity Theft Victim

Victim’s Last Name: First Name: Social Security Number (Please provide 9-digit Social Security Number): Current Street Mailing Address: City: State: Zip Code: Telephone Number: Alternate Telephone Number:

Email address:

Complete if applicable:

Victim’s Business Name: Business Owner(s) Name(s): Taxpayer Identification Number (EIN, TIN, or ITIN): _ Business Street Mailing Address: City: State: _ ZIP Code:

Section D – Declaration

Please carefully review the information you have provided in this form. Then review the statement provided below and, if appropriate, sign and date in the fields provided. Please remember you must sign this declaration by hand. Electronic signatures will not be accepted. If additional space is needed for any items, please attach additional pages.

I, , residing at hereby declare under penalty of perjury as follows:

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Please check and complete as appropriate:

On or about , I allege that someone used my personal identifying information (PII) or the identifying information of my business without my permission or knowledge to obtain a loan(s) in my name from the U.S. Small Business Administration or from a PPP Lender. Please include any known information about the loan (the loan or application number(s), amount(s) or any other details).

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State how you became aware that your identity was used to obtain this/these loan(s):

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I hereby confirm that the loan was not requested by me (or my business) nor did I authorize anyone to submit an application for me (or my business).

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I hereby confirm that none of the proceeds of the loan were used by me (or my business) or for my benefit or any other purpose that could benefit me (or my business).

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Are you aware of any other uses of your identity to borrow any other money, including obtaining credit cards, or to file state or federal income tax returns, if so please describe:

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You are required to attach and send with this form an official copy of a police report or an official report filed with a Federal law enforcement agency such as the FTC, FBI or United States Secret Service regarding this matter.

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You are required to attach and send with this form a copy of a valid driver license,

U.S. Passport, U.S. Military ID, or other valid ID issued by a state or federal agency.

I declare under penalty of perjury pursuant to 28 U.S.C. § 1746 that the information provided in this Declaration is based on my personal information and is true and correct.⁶

Date Signature of Declarant

PRIVACY ACT (5 U.S.C. § 552a)

Privacy Act (5 U.S.C. 552a) and Debt Collection Improvement Act (31 U.S.C. 7701)

Authorities and Purpose for Collecting Information: The Small Business Administration (SBA) requires this information collection for the administration of financial and contracting assistance programs. For financial assistance programs authorized by Sec. 7(a) of the Small Business Act, 15 U.S.C. § 636 et seq., and Title V of the Small Business Investment Act of 1958, 15 U.S.C. § 695, et seq. SBA is collecting the information on this form, including social security numbers and other personal information, to make decisions in connection with your declaration of identity theft.

SBA may also use social security numbers for the purpose of collecting and reporting on any delinquent fees or other amounts owed SBA, where applicable. For other individuals signing this form, the submission of the social security number is mandatory in order to investigate the identity theft claim and determine that the claimant did not receive any benefit. However, your social security number or other taxpayer identification number helps SBA 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: 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 for personal use of information is to assist in obtaining credit bureau reports on Disaster Loan Applicants and guarantors for purposes of originating, servicing, and liquidating Disaster loans. The information in this system is used on a routine basis exclusively by authorized officials. Personal information collected is protected to the extent permitted by law, including the Freedom Information Act, 5 U.S.C. 552, and the Privacy Act 5 U.S.C. 552a. While the records are routinely used only for the purpose for which they are established, additional uses may be made in accordance to SBA’s Privacy Act System of Records and any modifications: SBA 20 - Disaster Loans Case Files, SBA 21- Loan Systems, and SBA 26 - Power of Attorney Files. The notice of each system of records can be found here: https://www.sba.gov/sites/default/files/2020-01/sba-sorns.pdf.

Right to Financial Privacy Act of 1978 (12 U.S.C. 3401)

This is notice to you as required by the Right to 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, including any financial institutions participating in a loan or loan guarantee. 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 Government loan, loan guaranty agreement, or bond guarantee. SBA is required to provide a certificate of its compliance with the 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 accesses. The law also provides that SBA's access rights continue for the term of any approved loan or loan guaranty agreement, or 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 loan or bond guarantee, or concerning an approved loan or loan guarantee, or approved bond guarantee, as necessary to process, service or foreclose on a loan or loan guarantee or collect on a defaulted loan or loan guarantee, or 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.

Freedom of Information Act (5 U.S.C. 552)

This law provides, with some exceptions, that SBA must supply information contained in agency files and records to a person requesting it. Information about approved loans that will be automatically released includes, among other things, statistics on our loan programs (individual borrowers are not identified in the statistics), and other information such as the names of the borrowers (and their officers, directors, stockholders or partners), the collateral pledged to secure the loan, the amount of the loan, its purpose in general terms, and the maturity. Proprietary data on a borrower 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.

PLEASE NOTE: According to the 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 burden for completing this form, including time for reviewing instructions, gathering data needed, and completing and reviewing the form is 15 minutes. Comments or questions on the burden estimates should be sent to U.S. 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, Rm. 10202, Washington DC 20503. PLEASE DO NOT SEND THE FORM TO THESE ADDRESSES.

¹ If you are submitting this form for your business, by checking this box and signing the Declaration, you are indicating that you are an authorized representative of the business or the legal owner of the business.

² By checking this box and signing the Declaration, you are indicating that you are an authorized representative (as a parent, guardian, or legal guardian) to submit and sign on the minor’s behalfin compliance with the Children's Online Privacy Protection Rule ("COPPA"), 15 USC 6501.

³ By checking this box and signing the Declaration, you are indicating that you are the surviving spouse, the Court-Appointed or personal representative, Executor, or Administrator and that you are authorized to submit and sign the Declaration.

⁴ By checking this box and signing the Declaration, you are indicating that you have a Power of Attorney or are the Court-Appointed Guardian, or Conservator and that you are the authorized to submit and sign the Declaration.

⁵ Complete if someone other than the Identity Theft Victim is submitting the Declaration.

⁶ WARNING: In addition, any false statement or misrepresentation to SBA may result in criminal, civil or administrative sanctions including, but not limited to: 1) fines, imprisonment, or both, under 15 U.S.C. 645, 18 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.

SBA Form 3513 (08-24)