Court filing
Exhibit 1 — No. 1:23-cv-04875 (Dkt. 37-1, N.D. Ill.)
Summary
Exhibit 1 to Document 37 in United States ex rel. Aidan Forsyth v. KSO Metalfab, Inc. and Dora Kuzelka, No. 1:23-cv-04875, in the U.S. District Court for the Northern District of Illinois, filed April 14, 2026, is the defendants' amended memorandum in support of their Rule 12(b)(6) motion to dismiss. It recounts the government's allegations that Kuzelka, who owned 51% of KSO, answered "No" to the PPP application question on pending felony charges on March 16, 2021 and April 6, 2021, and that KSO received two loans of $416,727 each, which SBA forgave on June 29, 2022. The memorandum argues that the complaint does not plausibly allege causation and that treble damages and penalties of over $2.5 million would violate the Excessive Fines Clause of the Eighth Amendment. Attachments include a February 22, 2021 White House fact sheet and KSO's SBA Form 2483 and Form 2483-SD applications.
Summary drafted by a model from the document's text below and checked by script against that text before publication. It is a navigation aid, not a reading of what the document proves. Where AI is used
Filed April 14, 2026 in No. 1:23-cv-04875; one of 5 filings from this case.
Record facts
| Court | U.S. District Court for the Northern District of Illinois |
|---|---|
| Filed | 2026-04-14 |
Cite this document
“Exhibit 1 — No. 1:23-cv-04875 (Dkt. 37-1, N.D. Ill.).”
U.S. District Court for the Northern District of Illinois, No. 1:23-cv-04875, Doc. 37-1, filed 2026-04-14. Archived at Pandemic Darlings, https://pandemicdarlings.com/court-filings/aidan-forsyth-v-kso-metalfab-inc/2026-04-14-exhibit-1-to-dkt-37/
, SHA-256 915c16d73735b82f7169b1a2d47b6797f783c6fae0cee3d5fe8e693cd17d7f38.Full text
Case: 1:23-cv-04875 Document #: 37-1 Filed: 04/14/26 Page 1 of 51 PageID #:164
Exhibit 1
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IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ILLINOIS
EASTERN DIVISION
UNITED STATES OF AMERICA, ex rel., )
Aidan Forsyth, )
)
Plaintiff, )
)
v. ) No. 1:23-cv-04875
)
KSO METALFAB, INC., and DORA KUZELKA, ) Judge Manish S. Shah
)
Defendants. )
AMENDED MEMORANDUM IN SUPPORT OF DEFENDANTS’ RULE 12(b)(6)
MOTION TO DISMISS
Defendants, Dora Kuzelka (“Dora”) and KSO Metalfab, Inc (“KSO”), state as follows in
support of their Fed. R. Civ. P. 12(b)(6) Motion to Dismiss:
I. INTRODUCTION
The CARES Act was enacted on March 27, 2020 to provide immediate assistance to
individuals, families, and businesses affected by COVID-19. To this end, the Act authorized
Paycheck Protection Program loans (“PPP loans”). The Act provided that the PPP loans would be
forgiven if the loan proceeds were used for forgivable purposes. Over the course of the following
year leading up to submission of the loan applications that are the subject of the Government’s
case, there was a series of legislation, regulations, and guidance from governing bodies that
extended the time in which businesses could apply for PPP loans, increased the amounts that could
be borrowed, and expanded the businesses that were eligible for the PPP loans, including by
minimizing criminal histories of business owners that would disqualify their businesses from
receiving PPP loans. Less than a month before Dora submitted the loan applications at issue, the
Government advised the American public that businesses owned or controlled by individuals who
had pending felony charges for non-fraud related felonies were eligible for PPP loans.
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The Government does not allege that Dora or KSO used the PPP loan proceeds for any
improper purposes. Nor does it allege that other businesses were denied PPP funds because of the
loans made to KSO. Yet the relief sought by the Government is to impose treble damages totaling
over $2.5 million against Dora and KSO – the same relief the Government would have been
entitled to if Dora had misused the loan proceeds rather than using them for their intended
purposes.
The Complaint does not plausibly allege causation. In addition, the damages and penalties
sought by the Government are grossly disproportionate to the alleged conduct and its impact and
thus would violate the Excessive Fines Clause of the Eighth Amendment.
For these reasons, the Complaint should be dismissed.
II. ALLEGATIONS OF THE COMPLAINT
The Government alleges the following: On October 11, 2019, a criminal complaint was
lodged against Dora based on her facilitation of KSO employing individuals who were not legally
allowed to work in the United States. Dkt 26, ¶¶ 1, 30-31. Almost a year and a half later, Dora
applied for PPP loans on behalf of KSO on March 16, 2021, and April 6, 2021. Id. ¶¶ 35, 43. The
PPP loan applications included a question of whether the owner of more than 20% equity of the
applicant was “presently incarcerated or, for any felony, subject to an indictment, criminal
information, arraignment, or other means by which formal criminal charges are brought in any
jurisdiction.” Id. ¶¶ 37, 45. Dora answered “No” to this question in the applications for both loans.
Id. ¶¶ 37, 45. When Dora provided these answers, she owned 51% of the equity in KSO. Id. ¶¶
39, 46.
On May 3, 2022, Dora entered into a Non-Prosecution Agreement related to the criminal
charges that were then pending against her. Id. ¶ 33. Dora applied for forgiveness of the loans the
2
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following month, on June 22, 2022. Id. ¶¶ 41, 48. The United States Small Business
Administration (“SBA”) approved forgiveness of the loans on June 29, 2022. Id. ¶¶ 42, 49.
Based on Dora’s allegedly false answers, KSO received the two PPP loans, each in the
amount of $416,727. Id. ¶¶ 42, 49. The total amount paid by the Government for the loan principal,
interest and processing fees was $868,943. Id. ¶ 3. The Government seeks damages of three times
the amount of the PPP loans plus additional fines totaling over $2.5 million, not including interest.
Id. ¶ 24.
III. THE CARES ACT
The CARES Act (the “Act”) was enacted on March 27, 2020. SBA Interim Final Rule, 85
Fed. Reg. 20811 (Apr. 15, 2020). The purpose of the Act was to provide economic assistance to
individuals, families, and businesses nationwide that were adversely impacted by COVID-19 due
to the resulting dramatic decrease in economic activity. Id. To this end, the Act authorized the
“Paycheck Protection Program” loans and the forgiveness of those loans. Id. The forgiveness
provision meant that “the borrower will not be responsible for any loan payment if the borrower
uses all of the loan proceeds for forgivable purposes…” Id. at 20813.
The SBA’s Interim Final Rule became effective on April 15, 2020. Id. at 20811. Because
of the need to act immediately due to a dramatic decrease in economic activity across the country,
the SBA determined there was cause to dispense with the 30-day delayed effective date of the Rule
as provided in the Administrative Procedure Act and it certified that it would dispense with
conducting a regulatory impact analysis. Id. at 20811, 20817. The scope of the limitations on the
Act was reduced by further regulations effective on June 26, 2020, 85 FR 38301, and January 14,
2021, 86 Fed. Reg. 3692, each of which also became immediately effective for the same reasons.
On December 27, 2020, Congress took further action to expand the reach of the PPP loan program
by enacting the Economic Aid to Hard-Hit Small Businesses, Nonprofits, and Venues Act
3
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(Economic Aid Act). See, 86 Fed. Reg. 13149. The Economic Aid Act extended the authority to
make PPP loans through March 31, 2021, revised certain PPP requirements, and permitted second
draw loans. Id.
In the weeks immediately preceding KSO’s loan applications, the governing rules and
guidance were actively changing. On February 22, 2021, shortly after the Biden administration
took office, in a press briefing and release, the White House said it was “announcing several
reforms to build on [prior described] success by further targeting the PPP to the smallest businesses
and those that have been left behind in previous relief efforts.” Exhibit A, February 22, 2021
White House Fact Sheet. 1 Specifically, the administration announced the following:
Consistent with a bipartisan bill, eliminate an exclusionary restriction that prevents small
business owners with prior non-fraud felony convictions from obtaining relief through the
[PPP]. Currently, a business is ineligible for PPP if it is at least 20 percent owned by an
individual who has either: (a) an arrest or conviction for a felony related to financial
assistance fraud within the previous five years; or (2) any other felony within the previous
year. To expand access to PPP, the Biden-Harris administration will adopt bipartisan
reforms including the PPP Second Chance Act, co-sponsored by Senators Ben Cardin (D-
MD), Rob Portman (R-OH), and Cory Booker (D-NJ), and James Lankford (R-OK), which
would eliminate the second restriction (the one-year look-back) unless the applicant or
owner is incarcerated at the time of the application.
Id. (Emphasis added).
Thus, the Government announced to the American public that under the then-existing PPP
program, only charges or convictions for felonies related to financial assistance fraud during the
previous five years disqualified a party from applying for or receiving a PPP loan. The
Government further announced that the one-year look-back related to other felonies would be
eliminated unless the applicant was incarcerated at the time of the application.
1
It is appropriate for Defendants to rely on information of this nature because it is a matter of
public record. Johnson v. Darren Findling L. Firm, PLC, No. 22-CV-5517, 2023 WL 5289338,
at *6 (N.D. Ill. Aug. 17, 2023) (“[i]t's well established that judges may take judicial notice of
matters of public record when ruling on a motion to dismiss.”).
4
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Also on February 22, 2021, the SBA published on its official website that, to create an
inclusive economy, including for women-owned businesses, it would “[e]liminate an exclusionary
restriction on PPP access for small business owners with prior non-fraud felony convictions,
consistent with a bipartisan congressional proposal.” On March 8, 2021, the SBA revised its PPP
eligibility rules to expand loan access in a further interim final rule. In the accompanying
explanation, the SBA stated that it removed the one-year lookback for non-financial-fraud felonies
and retained only a five-year lookback for certain fraud-related offenses. 86 Fed. Reg. 13149. It
“remove[d] the eligibility restriction that prevents businesses with owners who have non-financial
fraud felony convictions in the last year from obtaining PPP loans.” Id.2
On March 16, 2021, Dora applied for KSO’s first loan using the application revised by the
SBA on March 3, 2021 (“First Draw”). See Exhibit B, KSO First Draw Application. The
application included the following questions:
5. Is the Applicant (if an individual) or any individual owning 20% or more of the
equity of the Applicant presently incarcerated or, for any felony, presently subject
to an indictment, criminal information, arraignment, or other means by which
formal criminal charges are brought in any Jurisdiction?
6. Within the last 5 years, for any felony involving fraud, bribery, embezzlement,
or a false statement in a loan application or an application for federal financial
assistance, or within the last year, for any other felony, has the Applicant (if an
individual) or any owner of the Applicant 1) been convicted; 2) pleaded guilty; 3)
pleaded nolo contendere; or 4) commenced any form of parole or probation
(including probation before judgment)?
Id. (emphasis added). Dora completed KSO’s second loan application on April 6, 2021, using the
SBA second draw application that was also revised by the SBA on March 3, 2021 (“Second
Draw”). See Exhibit C, KSO Second Draw Application. This form asked the same two questions
quoted above at paragraphs 4 and 5.
2
Illustrative of the SBA’s urgency in expanding the PPP loan program before the March 31, 2021
deadline for initial loans, the stated effective date of its March 8, 2021 interim final rule was March
4, 2021. Id.
5
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The first question (#5 in the First Draw and #4 in the Second Draw) required, at most, the
disclosure of felony charges, not all “pending criminal charges” as alleged in the Complaint. The
following question (#6 in the First Draw and #5 in the Second Draw), however, stated that only
convictions for “any felony involving fraud, bribery, embezzlement, or a false statement in a loan
application or an application for federal financial assistance” were disqualifying. Read together,
these questions appear to create ambiguity as to whether all pending felony charges were
disqualifying, particularly in light of contemporaneous guidance narrowing eligibility restrictions.
IV. ARGUMENT
A. Introduction
The False Claims Act imposes liability on any person who “knowingly presents, or causes
to be presented, a false or fraudulent claim for payment or approval.” Universal Health Services,
Inc. v. U.S. ex rel. Escobar, 579 U.S. 176, 182 (2016). To establish liability, a plaintiff must plead
four elements: 1) the defendant made a false statement (falsity); 2) the defendant knew the
statement was false (knowledge); 3) the false statement was material to the government’s payment
decision (materiality); and 4) the false statement caused the government’s loss (causation). United
States v. Carrington Mortgage Services, LLC, 70 F.4th 968, 973 (7th Cir. 2023).
Here, the Government has not alleged that Defendants misused the proceeds of the PPP
loans at issue. It does not allege that any other businesses were denied PPP funds because of the
loans made to KSO. Under the facts of this case, the Government has failed to plausibly plead
causation. Further, the penalties sought by the Government would violate the excessive fines
provision of the Eighth Amendment.
B. Dora’s Alleged Misrepresentations Did Not Cause the Government Any
Cognizable Loss
Earlier Seventh Circuit authority applied a “but for” causation standard for FCA claims
while all other circuits applied a proximate causation standard. United States v. Luce, 873 F.3d
6
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999, 1011 (7th Cir. 2017). The Seventh Circuit reconsidered this standard in light of the United
States Supreme Court’s decision in Universal Health Servs., Inc. v. United States ex rel. Escobar,
579 U.S. 176, 194-95 (2016). Although Escobar did not expressly address causation, in that case
the court “explicitly said that, ‘absent other indication, Congress intends to incorporate the well-
settled meaning of the common-law terms it uses’ and that ‘the term fraudulent is a paradigmatic
example of a statutory term that incorporates the common-law meaning of fraud.’” Id. (Emphasis
in original).
Based on the Escobar decision, the Luce court reached several conclusions relevant to the
causation requirement of the FCA. It found that “not all losses that in fact result from the reliance
are … legally caused by the representation…. Instead, ‘the misrepresentation is a legal cause only
of those pecuniary losses that are within the foreseeable risk of harm that it creates.’” Id. at 1011-
12. The court held that the “statutory language of the FCA does not suggest that Congress sought
to depart from the established common-law understanding of causation in fraud cases. The FCA
simply allows the Government to recover ‘damages which the Government sustains because of the
act of that person.’” Id. at 1012 (Emphasis in original). Accordingly, the court defined the issue
before it as “whether, under the proximate cause standard that we have enunciated today, the
Government can establish that [the defendant’s] falsehood was the proximate cause of the
Government’s harm.” Id. at 1014. The Seventh Circuit reiterated this requirement in United
States v. Carrington Mortg. Servs., LLC, 70 F.4th 968, 978-79 (7th Cir. 2023). Thus, as with a
traditional fraud claim, proximate cause of foreseeable harm or loss to the Government is a
necessary element of an FCA claim.
Here, the Complaint contains no such allegations. It does not allege that Dora’s
certifications caused any loss event, misuse of funds, or improper retention of PPP loan proceeds.
The only plausible inference from the Complaint is that the purposes for the PPP loan program
7
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were fulfilled by the loan to KSO. Absent any alleged causal connection between the purported
misrepresentation and a cognizable Government loss or harm, the Complaint fails to state a claim
under the FCA.
C. The Damages and Penalties Sought Are Unconstitutionally Excessive
The Eighth Amendment prohibits the imposition of “excessive fines.” The Excessive Fines
Clause applies to civil sanctions that are at least partly punitive, and the analysis proceeds in two
steps: (1) whether the sanction is punitive, and (2) whether it is “grossly disproportional to the
gravity of the offense.” United States v. Bajakajian, 524 U.S. 321, 322 (1998); see also Grashoff
v. Adams, 65 F.4th 910, 916 (7th Cir. 2023). The United States Supreme Court has determined that
“the FCA imposes damages that are essentially punitive in nature” Vermont Agency of Nat. Res. v.
U.S. ex rel. Stevens, 529 U.S. 765, 784 (2000) (“The very idea of treble damages reveals an intent
to punish past, and to deter future, unlawful conduct, not to ameliorate the liability of
wrongdoers.”).
Thus, the narrow question presented is whether, accepting the Complaint’s allegations as
true, the Government’s request for treble damages and per-claim penalties amounting to millions
of dollars is grossly disproportional to the gravity of the offense alleged in the Complaint. In
applying the proportionality standard, the Seventh Circuit evaluates whether there is a meaningful
relationship between the gravity of the alleged offense and the magnitude of the penalty sought.
Grashoff v. Adams, 65 F.4th 910, 917 (7th Cir. 2023). In Grashoff, the court distilled the inquiry
into several guideposts, including: (1) the essence of the offense and its relation to other unlawful
activity; (2) whether the defendant falls within the class of persons targeted by the statute; (3) the
statutory penalties authorized by Congress; and (4) the nature of the harm caused by the conduct.
Id. Although legislative judgments are entitled to deference, the analysis ultimately turns on
8
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whether there is an “articulable correlation” between the penalty imposed and the gravity of the
offense. Id. at 921.
Here, the Complaint does not allege a prolonged or systematic fraud scheme, misuse of
PPP funds, diversion of proceeds, or harm to program beneficiaries. Nor does it allege that
Defendants’ conduct caused financial loss beyond the Government’s assertion that it would not
have issued the loans had it known of the alleged ineligibility.
The Complaint does not allege conduct tied to other unlawful activity, does not place
Defendants within the core class of fraud-based actors targeted by the FCA’s most severe penalties,
and—most critically—does not allege any harm resulting from the use of the funds. On the face
of the Complaint, it does not allege any facts establishing an “articulable correlation” between the
gravity of the alleged conduct and the multi-million-dollar penalties sought. Grashoff, 65 F.4th at
921.
The Government’s case is based entirely on two written loan applications and two
forgiveness applications that were submitted to the SBA. Dora made the applications at a time
when the Biden administration considered her to be eligible to apply for the loans on behalf of
KSO, when the crime-related restrictions on applicants were being relaxed so that more businesses
would qualify for loans, and where the application forms for the loans counter-intuitively advised
that being charged with certain crimes was disqualifying while convictions for the same crimes
were not. The gravity of Dora’s alleged violations does not justify the imposition of the damages
sought by the Government.
Accepting the allegations of the Government’s Complaint as true, the penalties sought here
would be “grossly disproportional to the gravity of the offense” within the meaning of Seventh
Circuit precedent. Accordingly, the request for treble damages and statutory penalties should be
dismissed as violative of the Excessive Fines Clause.
9
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D. The Government Does Not State a Claim for Unjust Enrichment
The Government’s unjust enrichment claim is based on the same facts as its FCA claims.
Dkt. 26, p. 15. For this reason, the unjust enrichment claim will stand or fall along with the FCA
claims. Cleary v. Philip Morris, 656 F.3d 511, 517 (7th Cir. 2011). Defendants incorporate their
arguments above as the basis for dismissal of the unjust enrichment claim.
V. CONCLUSION
For the foregoing reasons, the Complaint fails to plausibly allege causation or harm under
the False Claims Act, and the penalties sought are unconstitutionally excessive. The Complaint
should therefore be dismissed in its entirety.
Date: April 14, 2026 Respectfully,
KSO Metalfab, Inc. and Dora Kuzelka
By: /s/Gary Hollander
Gary P. Hollander (ARDC #6181915)
Khoa Trinh (ARDC #6351044)
ARONBERG GOLDGEHN
225 W. Washington St. Suite 2800
Chicago, Illinois 60606
(312) 923-7336
ghollander@agdglaw.com
ktrinh@agdglaw.com
Counsel for Defendants
10
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CERTIFICATE OF SERVICE
I, Khoa D. Trinh, hereby certify that on April 14, 2026 I caused to be electronically filed
the foregoing AMENDED MEMORANDUM IN SUPPORT OF DEFENDANTS’ RULE
12(b)(6) MOTION TO DISMISS, true and correct copies of which will be served via the Court’s
EF/ECM system on all parties of record.
/s/ Khoa D. Trinh
11
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Exhibit A
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Case: 1:23-cv-04875 Document #: 37-1 Filed: 04/14/26 Page 17 of 51 PageID #:180
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Case: 1:23-cv-04875 Document #: 37-1 Filed: 04/14/26 Page 18 of 51 PageID #:181
Exhibit B
DocuSign Envelope ID: 6D03DFDC-552C-4AA2-BC05-33B65AC6A21E
Case: 1:23-cv-04875 Document #: 37-1 Filed: 04/14/26 Page 19 of 51 PageID #:182
Paycheck Protection Program OMB Control No.: 3245-0407
Borrower Application Form Revised March 3, 2021 Expiration Date: 9/30/2021
Check One: Sole proprietor Partnership ■ C-Corp S-Corp LLC
DBA or Tradename (if Year of Establishment (if
Independent contractor ( Self-employed
individual applicable) applicable)
501(c)(3) nonprofit 501(c)(6) organization
501(c)(19) veterans organization Housing cooperative KSO Metalfab Inc 1973
Tribal business Other ___________________________
Applicant (including affiliates,
Business Legal Name NAICS Code if applicable) Meets Size
Standard (check one):
■ No more than 500 employees
(or 300 employees, if applicable)
332999
unless “per location” exception
KSO Metalfab, Inc
applies
SBA industry size standards
SBA alternative size standard
Business Address (Street, City, State, Zip Code - No P.O. Box addresses Business TIN (EIN, SSN,
Business Phone
allowed) ITIN)
362761852 6303721200
250 Roma Jean Pkwy Streamwood, IL 60107 Primary Contact Email Address
Dora Kuzelka dorak@kso.com
x 2.5 + EIDL (Do Not Include
Average Monthly Number of
$ 166691 Any EIDL Advance) equals $ 416727 34
Payroll: Employees:
Loan Request Amount:
☐ Covered Operations
☐ Payroll Costs
■
☐ Rent / Mortgage Interest ☐ Utilities
Purpose of the Expenditures
loan (select all
that apply): ☐ Covered Property ☐ Covered Worker ☐ Other (explain):
☐ Covered Supplier Costs
Damage Protection Expenditures ______________________
Applicant Ownership
List all owners of 20% or more of the equity of the Applicant. Attach a separate sheet if necessary.
Owner Name Title Ownership % TIN (EIN, SSN, Address
ITIN)
Contained in supplemental information
PPP Applicant Demographic Information (Optional)
Veteran/gender/race/ethnicity data is collected for program reporting purposes only. Disclosure is voluntary and will have no bearing on the
loan application decision.
Principal Name Principal Position
Contained in supplemental information
Select Response Below:
Veteran ☐ Non-Veteran; ☐ Veteran; ☐ Service-Disabled Veteran; ☐ Spouse of Veteran; ☐ Not Disclosed
Gender ☐ Male; ☐ Female; ☐ Not Disclosed
Race (more than 1 ☐ American Indian or Alaska Native; ☐ Asian; ☐ Black or African-American; ☐ Native Hawaiian or Pacific Islander;
may be selected) ☐ White; ☐ Not Disclosed
Ethnicity ☐ Hispanic or Latino; ☐ Not Hispanic or Latino; ☐ Not Disclosed
SBA Form 2483 (3/21) 1
DocuSign Envelope ID: 6D03DFDC-552C-4AA2-BC05-33B65AC6A21E
Case: 1:23-cv-04875 Document #: 37-1 Filed: 04/14/26 Page 20 of 51 PageID #:183
Paycheck Protection Program
Borrower Application Form Revised March 3, 2021
If questions (1), (2), (5), or (6) are answered “Yes,” the loan will not be approved.
Question Yes No
1. Is the Applicant or any owner of the Applicant presently suspended, debarred, proposed for debarment, declared ineligible,
voluntarily excluded from participation in this transaction by any Federal department or agency, or presently involved in any ✔
bankruptcy?
2. Has the Applicant, any owner of the Applicant, or any business owned or controlled by any of them, ever obtained a direct or
guaranteed loan from SBA or any other Federal agency (other than a Federal student loan made or guaranteed through a program ✔
administered by the Department of Education) that is (a) currently delinquent, or (b) has defaulted in the last 7 years and caused a loss
to the government?
3. Is the Applicant or any owner of the Applicant an owner of any other business, or have common management (including a
management agreement) with any other business? If yes, list all such businesses (including their TINs if available) and describe the ✔
relationship on a separate sheet identified as addendum A.
4. Did the Applicant receive an SBA Economic Injury Disaster Loan between January 31, 2020 and April 3, 2020? If yes, provide ✔
details on a separate sheet identified as addendum B.
5. Is the Applicant (if an individual) or any individual owning 20% or more of the equity of the Applicant presently incarcerated or, for
any felony, presently subject to an indictment, criminal information, arraignment, or other means by which formal criminal charges ✔
are brought in any jurisdiction?
Initial here to confirm your response to question 5 → _____________________
6. Within the last 5 years, for any felony involving fraud, bribery, embezzlement, or a false statement in a loan application or an
application for federal financial assistance, has the Applicant (if an individual) or any owner of the Applicant 1) been convicted; 2) ✔
pleaded guilty; 3) pleaded nolo contendere; or 4) commenced any form of parole or probation (including probation before judgment)?
Initial here to confirm your response to question 6 → _____________________
7. Is the United States the principal place of residence for all employees included in the Applicant’s payroll calculation above? ✔
8. Is the Applicant a franchise? ✔
9. Is the franchise listed in SBA’s Franchise Directory? If yes, enter SBA Franchise Identifier Code here: _______________ ✔
SBA Form 2483 (3/21) 2
DocuSign Envelope ID: 6D03DFDC-552C-4AA2-BC05-33B65AC6A21E
Case: 1:23-cv-04875 Document #: 37-1 Filed: 04/14/26 Page 21 of 51 PageID #:184
Paycheck Protection Program
Borrower Application Form Revised March 3, 2021
By Signing Below, You Make the Following Representations, Authorizations, and Certifications
I certify that:
• I have read the statements included in this form, including the Statements Required by Law and Executive Orders, and I understand them.
• The Applicant is eligible to receive a loan under the rules in effect at the time this application is submitted that have been issued by the Small
Business Administration (SBA) and the Department of the Treasury (Treasury) implementing the Paycheck Protection Program under Division A,
Title I of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) and the Economic Aid to Hard-Hit Small Businesses, Nonprofits,
and Venues Act (the Paycheck Protection Program Rules).
• The Applicant, together with its affiliates (if applicable), (1) is an independent contractor, self-employed individual, or sole proprietor with no
employees; (2) if not a housing cooperative, eligible 501(c)(6) organization, or eligible destination marketing organization, employs no more than
the greater of 500 employees or, if applicable, the size standard in number of employees established by SBA in 13 C.F.R. 121.201 for the Applicant’s
industry; (3) if a housing cooperative, eligible 501(c)(6) organization, or eligible destination marketing organization, employs no more than 300
employees; (4) if NAICS 72, employs no more than 500 employees per physical location; (5) if a news organization that is majority owned or
controlled by a NAICS code 511110 or 5151 business or a nonprofit public broadcasting entity with a trade or business under NAICS code 511110
or 5151, employs no more than 500 employees (or, if applicable, the size standard in number of employees established by SBA in 13 C.F.R. 121.201
for the Applicant’s industry) per location; or (6) is a small business under the applicable revenue-based size standard established by SBA in 13
C.F.R. 121.201 for the Applicant’s industry or under the SBA alternative size standard.
• I will comply, whenever applicable, with the civil rights and other limitations in this form.
• All loan proceeds will be used only for business-related purposes as specified in the loan application and consistent with the Paycheck Protection
Program Rules including the prohibition on using loan proceeds for lobbying activities and expenditures. If Applicant is a news organization that
became eligible for a loan under Section 317 of the Economic Aid to Hard-Hit Small Businesses, Nonprofits, and Venues Act, proceeds of the loan
will be used to support expenses at the component of the business concern that produces or distributes locally focused or emergency information.
• I understand that SBA encourages the purchase, to the extent feasible, of American-made equipment and products.
• The Applicant is not engaged in any activity that is illegal under federal, state or local law.
• Any EIDL loan received by the Applicant (Section 7(b)(2) of the Small Business Act) between January 31, 2020 and April 3, 2020 was for a
purpose other than paying payroll costs and other allowable uses for loans under the Paycheck Protection Program Rules.
For Applicants who are individuals: 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 Act, as amended.
The authorized representative of the Applicant must certify in good faith to all of the below by initialing next to each one:
The Applicant was in operation on February 15, 2020, has not permanently closed, and was either an eligible self-employed individual,
independent contractor, or sole proprietorship with no employees, or had employees for whom it paid salaries and payroll taxes or paid independent
contractors, as reported on Form(s) 1099-MISC.
Current economic uncertainty makes this loan request necessary to support the ongoing operations of the Applicant.
The funds will be used to retain workers and maintain payroll; or make payments for mortgage interest, rent, utilities, covered operations
expenditures, covered property damage costs, covered supplier costs, and covered worker protection expenditures as specified under the Paycheck
Protection Program Rules; I understand that if the funds are knowingly used for unauthorized purposes, the federal government may hold me
legally liable, such as for charges of fraud.
I understand that loan forgiveness will be provided for the sum of documented payroll costs, covered mortgage interest payments, covered rent
payments, covered utilities, covered operations expenditures, covered property damage costs, covered supplier costs, and covered worker
protection expenditures, and not more than 40% of the forgiven amount may be for non-payroll costs. If required, the Applicant will provide to
the Lender and/or SBA documentation verifying the number of full-time equivalent employees on the Applicant’s payroll as well as the dollar
amounts of eligible expenses for the covered period following this loan.
The Applicant has not and will not receive another loan under the Paycheck Protection Program, section 7(a)(36) of the Small Business Act (15
U.S.C. 636(a)(36)) (this does not include Paycheck Protection Program second draw loans, section 7(a)(37) of the Small Business Act (15 U.S.C.
636(a)(37)).
The Applicant has not and will not receive a Shuttered Venue Operator grant from SBA.
_____ The President, the Vice President, the head of an Executive department, or a Member of Congress, or the spouse of such person as determined
under applicable common law, does not directly or indirectly hold a controlling interest in the Applicant, with such terms having the meanings
provided in Section 322 of the Economic Aid to Hard-Hit Small Businesses, Nonprofits, and Venues Act.
_____ The Applicant is not an issuer, the securities of which are listed on an exchange registered as a national securities exchange under section 6 of the
Securities Exchange Act of 1934 (15 U.S.C. 78f).
I further certify that the information provided in this application and the information provided in all supporting documents and forms is true and
accurate in all material respects. I understand that knowingly making a false statement to obtain a guaranteed loan from SBA 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.
I acknowledge that the Lender will confirm the eligible loan amount using required documents submitted. I understand, acknowledge, and agree
that the Lender can share any tax information that I have provided with SBA’s authorized representatives, including authorized representatives of
the SBA Office of Inspector General, for the purpose of compliance with SBA Loan Program Requirements and all SBA reviews.
_________________________________________________________ ________________________
3/16/2021
Signature of Authorized Representative of Applicant Date
___________________________________________
Dora Kuzelka ________________________
president
Print Name Title
SBA Form 2483 (3/21) 3
DocuSign Envelope ID: 6D03DFDC-552C-4AA2-BC05-33B65AC6A21E
Case: 1:23-cv-04875 Document #: 37-1 Filed: 04/14/26 Page 22 of 51 PageID #:185
Paycheck Protection Program
Borrower Application Form Revised March 3, 2021
Purpose of this form:
This form is to be completed by the authorized representative of the Applicant and submitted to your SBA Participating Lender. Submission of the requested
information is required to make a determination regarding eligibility for financial assistance. Failure to submit the information would affect that
determination.
An Applicant that files an IRS Form 1040, Schedule C, and elects to calculate the PPP loan amount using net profit must use this form. An Applicant that
files an IRS Form 1040, Schedule C, and elects to calculate the PPP loan amount using gross income cannot use this form, and instead must use SBA Form
2483-C. An Applicant that files an IRS Form 1040, Schedule F, and calculates the PPP loan amount using gross income must also use this form.
Instructions for completing this form:
With respect to Purpose of the Loan, payroll costs consist of compensation to employees (whose principal place of residence is the United States) in the
form of salary, wages, commissions, or similar compensation; cash tips or the equivalent (based on employer records of past tips or, in the absence of such
records, a reasonable, good-faith employer estimate of such tips); payment for vacation, parental, family, medical, or sick leave (except those paid leave
amounts for which a credit is allowed under FFCRA Sections 7001 and 7003); allowance for separation or dismissal; payment for the provision of employee
benefits (including insurance premiums) consisting of group health care coverage, group life, disability, vision, or dental insurance, and retirement benefits;
payment of state and local taxes assessed on compensation of employees; and, for an independent contractor or sole proprietor, wage, commissions, income,
or net earnings from self-employment or similar compensation.
For purposes of calculating Average Monthly Payroll, most Applicants will use the average monthly payroll for 2019 or 2020, excluding costs over $100,000
on an annualized basis, as prorated for the period during which the payments are made or the obligation to make the payments is incurred, for each employee.
For seasonal businesses, the Applicant may elect to instead use average total monthly payroll for any twelve-week period selected by the Applicant between
February 15, 2019 and February 15, 2020, excluding costs over $100,000 on an annualized basis, as prorated for the period during which the payments are
made or the obligation to make the payments is incurred, for each employee. For new businesses, average monthly payroll may be calculated using the time
period from January 1, 2020 to February 29, 2020, excluding costs over $100,000 on an annualized basis, as prorated for the period during which the
payments are made or the obligation to make the payments is incurred, for each employee. For farmers and ranchers that operate as a sole proprietorship or
as an independent contractor, or who are eligible self-employed individuals and report farm income or expenses on a Schedule F (or any equivalent successor
IRS form), payroll costs are computed using eligible payroll costs for employees, if any, plus the lesser of $100,000 and the difference between gross income
and any eligible payroll costs for employees, as reported on a Schedule F. For Applicants that file IRS Form 1040, Schedule C, and elect to calculate the
PPP loan amount using net profit, payroll costs are computed using line 31 net profit amount, limited to $100,000, plus any eligible payroll costs for
employees (to calculate loan amount using gross income, see SBA Form 2483-C). For Applicants that are partnerships, payroll costs are computed using
net earnings from self-employment of individual general partners, as reported on IRS Form 1065 K-1, reduced by section 179 expense deduction claimed,
unreimbursed partnership expenses claimed, and depletion claimed on oil and gas properties, multiplied by 0.9235, that is not more than $100,000, plus any
eligible payroll costs for employees.
For purposes of reporting Number of Employees, sole proprietors, self-employed individuals, and independent contractors should include themselves as
employees (i.e., the minimum number in the box Number of Employees is one). Applicants may use their average employment over the time period used
to calculate their aggregate payroll costs to determine their number of employees. Alternatively, Applicants may elect to use the average number of
employees per pay period in the 12 completed calendar months prior to the date of the loan application.
For purposes of reporting Year of Establishment, self-employed individuals and independent contractors may enter “NA”.
For purposes of reporting NAICS Code, applicants must match the business activity code provided on their IRS income tax filings, if applicable.
If Applicant is refinancing an Economic Injury Disaster Loan (EIDL): Add the outstanding amount of an EIDL made between January 31, 2020 and April
3, 2020 to Loan Request as indicated on the form. Do not add the amount of any EIDL Advance.
All parties listed below are considered owners of the Applicant:
• For a sole proprietorship, the sole proprietor;
• For a partnership, all general partners, and all limited partners owning 20% or more of the equity of the firm;
• For a corporation, all owners of 20% or more of the corporation;
• For limited liability companies, all members owning 20% or more of the company; and
• Any Trustor (if the Applicant is owned by a trust).
For purposes of reporting (optional) demographic information:
1. Purpose. Veteran/gender/race/ethnicity data is collected for program reporting purposes only.
2. Description. This form requests information about each of the Applicant’s Principals. Add additional sheets if necessary.
3. Definition of Principal. The term “Principal” means:
• For a self-employed individual, independent contractor, or a sole proprietor, the self-employed individual, independent contractor, or sole
proprietor.
• For a partnership, all general partners and all limited partners owning 20% or more of the equity of the Applicant, or any partner that is
involved in the management of the Applicant’s business.
• For a corporation, all owners of 20% or more of the Applicant, and each officer and director.
• For a limited liability company, all members owning 20% or more of the Applicant, and each officer and director.
• Any individual hired by the Applicant to manage the day-to-day operations of the Applicant (“key employee”).
• Any trustor (if the Applicant is owned by a trust).
• For a nonprofit organization, the officers and directors of the Applicant.
4. Principal Name. Insert the full name of the Principal.
5. Principal Position. Identify the Principal’s position; for example, self-employed individual; independent contractor; sole proprietor; general
partner; owner; officer; director; member; or key employee.
SBA Form 2483 (3/21) 4
DocuSign Envelope ID: 6D03DFDC-552C-4AA2-BC05-33B65AC6A21E
Case: 1:23-cv-04875 Document #: 37-1 Filed: 04/14/26 Page 23 of 51 PageID #:186
Paycheck Protection Program
Borrower Application Form Revised March 3, 2021
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 application, including gathering data needed, is 8 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.
Privacy Act (5 U.S.C. 552a) – Under the provisions of the Privacy Act, you are not required to provide your social security number. Failure to provide your
social security number may not affect any right, benefit or privilege to which you are entitled. (But see Debt Collection Notice regarding taxpayer
identification number below.) Disclosures of name and other personal identifiers are required to provide SBA with sufficient information to make a character
determination. When evaluating character, SBA considers the person’s integrity, candor, and disposition toward criminal actions. Additionally, SBA is
specifically authorized to verify your criminal history, or lack thereof, pursuant to section 7(a)(1)(B), 15 U.S.C. Section 636(a)(1)(B) of the Small Business
Act.
Disclosure of Information – Requests for information about another party may be denied unless SBA has the written permission of the individual to release
the information to the requestor or unless the information is subject to disclosure under the Freedom of Information Act. The Privacy Act authorizes SBA
to make certain “routine uses” of information protected by that Act. One such routine use is the disclosure of information maintained in SBA’s system of
records when this information indicates a violation or potential violation of law, whether civil, criminal, or administrative in nature. Specifically, SBA may
refer the information 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 is disclosure to other Federal agencies conducting background
checks but only to the extent the information is relevant to the requesting agencies’ function. See, 74 F.R. 14890 (2009), and as amended from time to time
for additional background and other routine uses. In addition, the CARES Act, requires SBA to register every loan made under the Paycheck Protection
Program using the Taxpayer Identification Number (TIN) assigned to the borrower.
Debt Collection Act of 1982, Deficit Reduction Act of 1984 (31 U.S.C. 3701 et seq. and other titles) – SBA must obtain your taxpayer identification
number when you apply for a loan. If you receive a loan, and do not make payments as they come due, SBA may: (1) report the status of your loan(s) to
credit bureaus, (2) hire a collection agency to collect your loan, (3) offset your income tax refund or other amounts due to you from the Federal Government,
(4) suspend or debar you or your company from doing business with the Federal Government, (5) refer your loan to the Department of Justice, or (6) take
other action permitted in the loan instruments.
Right to Financial Privacy Act of 1978 (12 U.S.C. 3401) – The Right to Financial Privacy Act of 1978, grants SBA 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
guaranty. SBA is only required 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. SBA’s access rights continue for the term of any approved loan guaranty agreement. SBA is also authorized to transfer to another
Government authority any financial records concerning an approved loan or loan guarantee, as necessary to process, service or foreclose on a loan guaranty
or collect on a defaulted loan guaranty.
Freedom of Information Act (5 U.S.C. 552) – This law provides, with some exceptions, that SBA must supply information reflected in agency files and
records to a person requesting it. Information about approved loans that is generally 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, the amount of the loan, and the type of
the loan. 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.
Occupational Safety and Health Act (15 U.S.C. 651 et seq.) – The Occupational Safety and Health Administration (OSHA) can require businesses to
modify facilities and procedures to protect employees. Businesses that do not comply may be fined and required to abate the hazards in their workplaces.
They may also be ordered to cease operations posing an imminent danger of death or serious injury until employees can be protected. Signing this form is
certification that the applicant, to the best of its knowledge, is in compliance with the applicable OSHA requirements, and will remain in compliance during
the life of the loan.
Civil Rights (13 C.F.R. 112, 113, 117) – All businesses receiving SBA financial 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 112, 113, and 117 of SBA Regulations. All borrowers
must display the "Equal Employment Opportunity Poster" prescribed by SBA.
Equal Credit Opportunity Act (15 U.S.C. 1691) – Creditors are prohibited from discriminating against credit applicants on the basis of race, color, religion,
national origin, sex, marital status or age (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant’s
income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection
Act.
Debarment and Suspension Executive Order 12549 (2 C.F.R. Part 180 and Part 2700) – By submitting this loan application, you certify that neither
the Applicant or any owner of the Applicant have within the past three years been: (a) debarred, suspended, declared ineligible or voluntarily excluded from
participation in a transaction by any Federal 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 owed to the U.S. Government
or its instrumentalities as of the date of execution of this certification.
SBA Form 2483 (3/21) 5
DocuSign Envelope ID: 6D03DFDC-552C-4AA2-BC05-33B65AC6A21E
Case: 1:23-cv-04875 Document #: 37-1 Filed: 04/14/26 Page 24 of 51 PageID #:187
PPP Applicant Ownership Sheet
Owner Name Title Ownership % TIN (EIN, SSN) Address
Dora Kuzelka President 51 362761852 250 Roma Jean Pkwy, Streamwood, IL 60107
SBA Form 2483 (3/21) 6
DocuSign Envelope ID: 6D03DFDC-552C-4AA2-BC05-33B65AC6A21E
Case: 1:23-cv-04875 Document #: 37-1 Filed: 04/14/26 Page 25 of 51 PageID #:188
PPP Borrower Demographic Information Sheet
Principal Name Position Veteran Gender Race Ethnicity
Dora Kuzelka President 1=Non-Veteran F=Female 5=White N=Not Hispanic or Latino
SBA Form 2483 (3/21) 7
Case: 1:23-cv-04875 Document #: 37-1 Filed: 04/14/26 Page 26 of 51 PageID #:189
Exhibit C
DocuSign Envelope ID: 3219560E-CE5D-4A77-8B92-95A542985321
Case: 1:23-cv-04875 Document #: 37-1 Filed: 04/14/26 Page 27 of 51 PageID #:190
Paycheck Protection Program OMB Control No.: 3245-0417
Second Draw Borrower Application Form Expiration Date: 9/30/2021
Revised March 3, 2021
Check One: (
Sole proprietor Partnership ■
C-Corp S-Corp LLC DBA or Tradename (if Year of Establishment (if
Independent contractor Self-employed individual applicable) applicable)
501(c)(3) nonprofit 501(c)(6) organization
501(c)(19) veterans organization Housing cooperative KSO METALFAB, 1973
Tribal business Other _ ___________________________ INC.
Business Legal Name NAICS Code
KSO METALFAB, INC. 332999
Business Address (Street, City, State, Zip Code - No P.O. Box addresses Business TIN (EIN, SSN, Business Phone
allowed) ITIN)
362761852 6303721200
250 Roma Jean Pkwy Streamwood, IL 60107 Primary Contact Email Address
DORA KUZELKA dorak@kso.com
Number of Employees
x 2.5 (or x 3.5 for NAICS
(including affiliates, if
Average Monthly 72 applicants) equals Loan
$ 166691 $ 416727 applicable; may not exceed 34
Payroll: Request Amount (may not
300 unless “per location”
exceed $2,000,000):
exception applies):
☐Payroll Costs
■
☐Rent / Mortgage Interest
■
☐Utilities
■ ☐Covered Operations
■
Purpose of the Expenditures
loan (select all that
apply): ☐Covered Property
■
☐Covered Supplier Costs
■ ☐Covered Worker
■
☐Other (explain):
Damage Protection Expenditures ______________________
PPP First Draw
SBA Loan Number: 4166398610
Reduction in Gross Receipts of at Least 2020 Quarter Reference Quarter
25% (Applicants for loans of $150,000 or (e.g., 2Q 2020):
1Q 2020 (e.g., 2Q 2019):
1Q 2019
less may leave blank but must provide
upon or before seeking loan forgiveness Gross Receipts: $ 1290497 Gross Receipts $ 1809013
or upon SBA request):
Applicant Ownership
List all owners of 20% or more of the equity of the Applicant. Attach a separate sheet if necessary.
Owner Name Title Ownership % TIN (EIN, SSN, Address
ITIN)
Contained in supplemental information
PPP Applicant Demographic Information (Optional)
Veteran/gender/race/ethnicity data is collected for program reporting purposes only. Disclosure is voluntary and will have no bearing on the
loan application decision.
Principal Name Principal Position
Contained in supplemental information
Select Response Below:
Veteran ☐ Non-Veteran; ☐ Veteran; ☐ Service-Disabled Veteran; ☐ Spouse of Veteran; ☐ Not Disclosed
Gender ☐ Male; ☐ Female; ☐ Not Disclosed
Race (more than 1 may ☐ American Indian or Alaska Native; ☐ Asian; ☐ Black or African-American;
be selected) ☐ Native Hawaiian or Pacific Islander; ☐ White; ☐ Not Disclosed
Ethnicity ☐ Hispanic or Latino; ☐ Not Hispanic or Latino; ☐ Not Disclosed
SBA Form 2483-SD (3/21) 1
DocuSign Envelope ID: 3219560E-CE5D-4A77-8B92-95A542985321
Case: 1:23-cv-04875 Document #: 37-1 Filed: 04/14/26 Page 28 of 51 PageID #:191
Paycheck Protection Program
Second Draw Borrower Application Form
Revised March 3, 2021
If questions (1), (2), (4), or (5) are answered “Yes,” the loan will not be approved.
Question Yes No
1. Is the Applicant or any owner of the Applicant presently suspended, debarred, proposed for debarment, declared ineligible,
voluntarily excluded from participation in this transaction by any Federal department or agency, or presently involved in any ✔
bankruptcy?
2. Has the Applicant, any owner of the Applicant, or any business owned or controlled by any of them, ever obtained a direct or
guaranteed loan from SBA or any other Federal agency (other than a Federal student loan made or guaranteed through a program ✔
administered by the Department of Education) that is (a) currently delinquent, or (b) has defaulted in the last 7 years and caused a loss
to the government?
3. Is the Applicant or any owner of the Applicant an owner of any other business, or have common management (including a
management agreement) with any other business? If yes, list all such businesses (including their TINs if available) and describe the ✔
relationship on a separate sheet identified as addendum A.
4. Is the Applicant (if an individual) or any individual owning 20% or more of the equity of the Applicant presently incarcerated or, for
any felony, presently subject to an indictment, criminal information, arraignment, or other means by which formal criminal charges ✔
are brought in any jurisdiction?
Initial here to confirm your response to question 4 →
5. Within the last 5 years, for any felony involving fraud, bribery, embezzlement, or a false statement in a loan application or an
application for federal financial assistance, has the Applicant (if an individual) or any owner of the Applicant 1) been convicted; 2) ✔
pleaded guilty; 3) pleaded nolo contendere; or 4) commenced any form of parole or probation (including probation before judgment)?
Initial here to confirm your response to question 5 →
6. Is the United States the principal place of residence for all employees included in the Applicant’s payroll calculation above? ✔
7. Is the Applicant a franchise? ✔
8. Is the franchise listed in SBA’s Franchise Directory? If yes, enter SBA Franchise Identifier Code here: _______________ ✔
SBA Form 2483-SD (3/21) 2
DocuSign Envelope ID: 3219560E-CE5D-4A77-8B92-95A542985321
Case: 1:23-cv-04875 Document #: 37-1 Filed: 04/14/26 Page 29 of 51 PageID #:192
Paycheck Protection Program
Second Draw Borrower Application Form
Revised March 3, 2021
By Signing Below, You Make the Following Representations, Authorizations, and Certifications
I certify that:
• I have read the statements included in this form, including the Statements Required by Law and Executive Orders, and I understand them.
• The Applicant is eligible to receive a loan under the rules in effect at the time this application is submitted that have been issued by the Small
Business Administration (SBA) and the Department of the Treasury (Treasury) implementing Second Draw Paycheck Protection Program Loans
under Division A, Title I of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) and the Economic Aid to Hard-Hit Small
Businesses, Nonprofits, and Venues Act (the Paycheck Protection Program Rules).
• The Applicant, together with its affiliates (if applicable), (1) is an independent contractor, self-employed individual, or sole proprietor with no
employees; (2) employs no more than 300 employees; or (3) if NAICS 72, employs no more than 300 employees per physical location; (4) if a
news organization that is majority owned or controlled by a NAICS code 511110 or 5151 business or a nonprofit public broadcasting entity with
a trade or business under NAICS code 511110 or 5151, employs no more than 300 employees per location.
• I will comply, whenever applicable, with the civil rights and other limitations in this form.
• All loan proceeds will be used only for business-related purposes as specified in the loan application and consistent with the Paycheck Protection
Program Rules including the prohibition on using loan proceeds for lobbying activities and expenditures. If Applicant is a news organization
that became eligible for a loan under Section 317 of the Economic Aid to Hard-Hit Small Businesses, Nonprofits, and Venues Act, proceeds of
the loan will be used to support expenses at the component of the business concern that produces or distributes locally focused or emergency
information.
• I understand that SBA encourages the purchase, to the extent feasible, of American-made equipment and products.
• The Applicant is not engaged in any activity that is illegal under federal, state or local law.
For Applicants who are individuals: 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 Act, as amended.
The authorized representative of the Applicant must certify in good faith to all of the below by initialing next to each one:
The Applicant was in operation on February 15, 2020, has not permanently closed, and was either an eligible self-employed individual,
independent contractor, or sole proprietorship with no employees, or had employees for whom it paid salaries and payroll taxes or paid
independent contractors, as reported on Form(s) 1099-MISC.
Current economic uncertainty makes this loan request necessary to support the ongoing operations of the Applicant.
The Applicant has realized a reduction in gross receipts in excess of 25% relative to the relevant comparison time period. For loans greater
than $150,000, Applicant has provided documentation to the lender substantiating the decline in gross receipts. For loans of $150,000 or
less, Applicant will provide documentation substantiating the decline in gross receipts upon or before seeking loan forgiveness for the Second
Draw Paycheck Protection Program Loan or upon SBA request.
The Applicant received a First Draw Paycheck Protection Program Loan and, before the Second Draw Paycheck Protection Program Loan
is disbursed, will have used the full loan amount (including any increase) of the First Draw Paycheck Protection Program Loan only for
eligible expenses.
The funds will be used to retain workers and maintain payroll; or make payments for mortgage interest, rent, utilities, covered operations
expenditures, covered property damage costs, covered supplier costs, and covered worker protection expenditures as specified under the
Paycheck Protection Program Rules; I understand that if the funds are knowingly used for unauthorized purposes, the federal government
may hold me legally liable, such as for charges of fraud.
I understand that loan forgiveness will be provided for the sum of documented payroll costs, covered mortgage interest payments, covered
rent payments, covered utilities, covered operations expenditures, covered property damage costs, covered supplier costs, and covered worker
protection expenditures, and not more than 40% of the forgiven amount may be for non-payroll costs. If required, the Applicant will provide
to the Lender and/or SBA documentation verifying the number of full-time equivalent employees on the Applicant’s payroll as well as the
dollar amounts of eligible expenses for the covered period following this loan.
_____ The Applicant has not and will not receive another Second Draw Paycheck Protection Program Loan.
The Applicant has not and will not receive a Shuttered Venue Operator grant from SBA.
SBA Form 2483-SD (3/21) 3
DocuSign Envelope ID: 3219560E-CE5D-4A77-8B92-95A542985321
Case: 1:23-cv-04875 Document #: 37-1 Filed: 04/14/26 Page 30 of 51 PageID #:193
Paycheck Protection Program
Second Draw Borrower Application Form
Revised March 3, 2021
The President, the Vice President, the head of an Executive department, or a Member of Congress, or the spouse of such person as determined
under applicable common law, does not directly or indirectly hold a controlling interest in the Applicant, with such terms having the meanings
provided in Section 322 of the Economic Aid to Hard-Hit Small Businesses, Nonprofits, and Venues Act.
The Applicant is not an issuer, the securities of which are listed on an exchange registered as a national securities exchange under section 6
of the Securities Exchange Act of 1934 (15 U.S.C. 78f).
The Applicant is not a business concern or entity (a) for which an entity created in or organized under the laws of the People’s Republic of
China or the Special Administrative Region of Hong Kong, or that has significant operations in the People’s Republic of China or the Special
Administrative Region of Hong Kong, owns or holds, directly or indirectly, not less than 20 percent of the economic interest of the business
concern or entity, including as equity shares or a capital or profit interest in a limited liability company or partnership; or (b) that retains, as
a member of the board of directors of the business concern, a person who is a resident of the People’s Republic of China.
The Applicant is not required to submit a registration statement under section 2 of the Foreign Agents Registration Act of 1938 (22 U.S.C.
612).
The Applicant is not a business concern or entity primarily engaged in political or lobbying activities, including any entity that is organized
for research or for engaging in advocacy in areas such as public policy or political strategy or otherwise describes itself as a think tank in any
public documents.
I further certify that the information provided in this application and the information provided in all supporting documents and forms is true
and accurate in all material respects. I understand that knowingly making a false statement to obtain a guaranteed loan from SBA 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.
I acknowledge that the Lender will confirm the eligible loan amount using required documents submitted. I understand, acknowledge, and
agree that the Lender can share any tax information that I have provided with SBA’s authorized representatives, including authorized
representatives of the SBA Office of Inspector General, for the purpose of compliance with SBA Loan Program Requirements and all SBA
reviews.
_________________________________________________________ ________________________
4/6/2021
Signature of Authorized Representative of Applicant Date
DORA KUZELKA
___ ______________________________________________________ PRESIDENT
________________________
Print Name Title
SBA Form 2483-SD (3/21) 4
DocuSign Envelope ID: 3219560E-CE5D-4A77-8B92-95A542985321
Case: 1:23-cv-04875 Document #: 37-1 Filed: 04/14/26 Page 31 of 51 PageID #:194
Paycheck Protection Program
Second Draw Borrower Application Form
Revised March 3, 2021
Purpose of this form:
This form is to be completed by the authorized representative of the Applicant and submitted to your SBA Participating Lender. Submission of the requested
information is required to make a determination regarding eligibility for financial assistance. Failure to submit the information would affect that
determination.
An Applicant that files an IRS Form 1040, Schedule C, and elects to calculate the PPP loan amount using net profit must use this form. An Applicant that
files an IRS Form 1040, Schedule C, and elects to calculate the PPP loan amount using gross income cannot use this form, and instead must use SBA Form
2483-SD-C. An Applicant that files an IRS Form 1040, Schedule F, and calculates the PPP loan amount using gross income must also use this form.
Instructions for completing this form:
With respect to Purpose of the Loan, payroll costs consist of compensation to employees (whose principal place of residence is the United States) in the
form of salary, wages, commissions, or similar compensation; cash tips or the equivalent (based on employer records of past tips or, in the absence of such
records, a reasonable, good-faith employer estimate of such tips); payment for vacation, parental, family, medical, or sick leave (except those paid leave
amounts for which a credit is allowed under FFCRA Sections 7001 and 7003); allowance for separation or dismissal; payment for the provision of employee
benefits (including insurance premiums) consisting of group health care coverage, group life, disability, vision, or dental insurance, and retirement benefits;
payment of state and local taxes assessed on compensation of employees; and, for an independent contractor or sole proprietor, wage, commissions, income,
or net earnings from self-employment or similar compensation.
For purposes of calculating Average Monthly Payroll, most Applicants will use the average monthly payroll for 2019 or 2020, excluding costs over $100,000
on an annualized basis, as prorated for the period during which the payments are made or the obligation to make the payments is incurred, for each employee.
For seasonal businesses, the Applicant may elect to instead use average total monthly payroll for any twelve-week period selected by the Applicant between
February 15, 2019 and February 15, 2020, excluding costs over $100,000 on an annualized basis, as prorated for the period during which the payments are
made or the obligation to make the payments is incurred, for each employee. For new businesses without 12 months of payroll costs but that were in operation
on February 15, 2020, average monthly payroll may be calculated based on the number of months in which payroll costs were incurred, excluding costs
over $100,000 on an annualized basis for each employee, as prorated for the period during which the payments are made or the obligation to make the
payments is incurred, for each employee. For farmers and ranchers that operate as a sole proprietorship or as an independent contractor, or who are eligible
self-employed individuals and report farm income or expenses on a Schedule F (or any equivalent successor IRS form), payroll costs are computed using
eligible payroll costs for employees, if any, plus the lesser of $100,000 and the difference between gross income and any eligible payroll costs for employees,
as reported on a Schedule F. For Applicants that file IRS Form 1040, Schedule C, and elect to calculate the PPP loan amount using net profit, payroll costs
are computed using line 31 net profit amount, limited to $100,000, plus any eligible payroll costs for employees (to calculate loan amount using gross
income, see SBA Form 2483-SD-C). For Applicants that are partnerships, payroll costs are computed using net earnings from self-employment of individual
general partners, as reported on IRS Form 1065 K-1, reduced by section 179 expense deduction claimed, unreimbursed partnership expenses claimed, and
depletion claimed on oil and gas properties, multiplied by 0.9235, that is not more than $100,000, plus any eligible payroll costs for employees.
In determining whether the Applicant experienced at least a 25% reduction in gross receipts, for loans above $150,000, the Applicant must identify the 2020
quarter meeting this requirement, identify the reference quarter, and state the gross receipts amounts for both quarters, as well as provide supporting
documentation. For loans of $150,000 and below, these fields are not required and the Applicant only must certify that the Applicant has met the 25% gross
receipts reduction at the time of application; however, upon or before seeking loan forgiveness (or upon SBA request) the Applicant must provide
documentation that identifies the 2020 quarter meeting this requirement, identifies the reference quarter, states the gross receipts amounts for both quarters,
and supports the amounts provided. For all loans, the appropriate reference quarter depends on how long the Applicant has been in operation:
• For all Applicants other than those satisfying the conditions set forth below, Applicants must demonstrate that gross receipts in any quarter of 2020
were at least 25% lower than the same quarter of 2019. Alternatively, Applicants may compare annual gross receipts in 2020 with annual gross receipts
in 2019; Applicants choosing to use annual gross receipts must enter “Annual” in the 2020 Quarter and Reference Quarter fields and, as required
documentation, must submit copies of annual tax forms substantiating the annual gross receipts reduction.
• For Applicants not in business during the first and second quarters of 2019 but in operation during the third and fourth quarters of 2019, Applicants
must demonstrate that gross receipts in any quarter of 2020 were at least 25% lower than either the third or fourth quarters of 2019.
• For Applicants not in business during the first, second, and third quarters of 2019 but in operation during the fourth quarter of 2019, Applicants must
demonstrate that gross receipts in any quarter of 2020 were at least 25% lower than the fourth quarter of 2019.
• For Applicants not in business during 2019 but in operation on February 15, 2020, Applicants must demonstrate that gross receipts in the second, third,
or fourth quarter of 2020 were at least 25% lower than the first quarter of 2020.
Gross receipts includes all revenue in whatever form received or accrued (in accordance with the Applicant’s accounting method) from whatever source,
including from the sales of products or services, interest, dividends, rents, royalties, fees, or commissions, reduced by returns and allowances. Generally,
receipts are considered “total income” (or in the case of a sole proprietorship “gross income”) plus “cost of goods sold” and excludes net capital gains or
losses as these terms are defined and reported on IRS tax return forms. Gross receipts do not include the following: taxes collected for and remitted to a
taxing authority if included in gross or total income, such as sales or other taxes collected from customers and excluding taxes levied on the concern or its
employees; proceeds from transactions between a concern and its domestic or foreign affiliates; and amounts collected for another by a travel agent, real
estate agent, advertising agent, conference management service provider, freight forwarder or customs broker. All other items, such as subcontractor costs,
reimbursements for purchases a contractor makes at a customer's request, investment income, and employee-based costs such as payroll taxes, may not be
excluded from gross receipts. Gross receipts of an Applicant must be aggregated with gross receipts of its affiliates. For a nonprofit organization, veterans
organization, nonprofit news organization, 501(c)(6) organization, and destination marketing organization, gross receipts has the meaning in section 6033
of the Internal Revenue Code of 1986.
SBA Form 2483-SD (3/21) 5
DocuSign Envelope ID: 3219560E-CE5D-4A77-8B92-95A542985321
Case: 1:23-cv-04875 Document #: 37-1 Filed: 04/14/26 Page 32 of 51 PageID #:195
Paycheck Protection Program
Second Draw Borrower Application Form
Revised March 3, 2021
For purposes of reporting Number of Employees, sole proprietors, self-employed individuals, and independent contractors should include themselves as
employees (i.e., the minimum number in the box Number of Employees is one). For NAICS 72 or eligible news organizations, applicants may not exceed
300 per physical location. Applicants may use their average employment over the time period used to calculate their aggregate payroll costs to determine
their number of employees. Alternatively, Applicants may elect to use the average number of employees per pay period in the 12 completed calendar months
prior to the date of the loan application.
For purposes of reporting Year of Establishment, self-employed individuals and independent contractors may enter “NA”.
For purposes of reporting NAICS Code, applicants must match the business activity code provided on their IRS income tax filings, if applicable. For
purposes of calculating an Applicant’s maximum payroll costs, an Applicant may multiply its average monthly payroll costs by 3.5 only if the Applicant is
in the Accommodation and Food Services sector and has reported a NAICS code beginning with 72 as its business activity code on its most recent IRS
income tax return.
All parties listed below are considered owners of the Applicant:
• For a sole proprietorship, the sole proprietor;
• For a partnership, all general partners, and all limited partners owning 20% or more of the equity of the firm;
• For a corporation, all owners of 20% or more of the corporation;
• For limited liability companies, all members owning 20% or more of the company; and
• Any Trustor (if the Applicant is owned by a trust).
For purposes of reporting (optional) demographic information:
1. Purpose. Veteran/gender/race/ethnicity data is collected for program reporting purposes only.
2. Description. This form requests information about each of the Applicant’s Principals. Add additional sheets if necessary.
3. Definition of Principal. The term “Principal” means:
• For a self-employed individual, independent contractor, or a sole proprietor, the self-employed individual, independent contractor, or sole
proprietor.
• For a partnership, all general partners and all limited partners owning 20% or more of the equity of the Applicant, or any partner that is
involved in the management of the Applicant’s business.
• For a corporation, all owners of 20% or more of the Applicant, and each officer and director.
• For a limited liability company, all members owning 20% or more of the Applicant, and each officer and director.
• Any individual hired by the Applicant to manage the day-to-day operations of the Applicant (“key employee”).
• Any trustor (if the Applicant is owned by a trust).
• For a nonprofit organization, the officers and directors of the Applicant.
4. Principal Name. Insert the full name of the Principal.
5. Principal Position. Identify the Principal’s position; for example, self-employed individual; independent contractor; sole proprietor; general
partner; owner; officer; director; member; or key employee.
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 application, including gathering data needed, is 8 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.
Privacy Act (5 U.S.C. 552a) – Under the provisions of the Privacy Act, you are not required to provide your social security number. Failure to provide your
social security number may not affect any right, benefit or privilege to which you are entitled. (But see Debt Collection Notice regarding taxpayer
identification number below.) Disclosures of name and other personal identifiers are required to provide SBA with sufficient information to make a character
determination. When evaluating character, SBA considers the person’s integrity, candor, and disposition toward criminal actions. Additionally, SBA is
specifically authorized to verify your criminal history, or lack thereof, pursuant to section 7(a)(1)(B), 15 U.S.C. 636(a)(1)(B) of the Small Business Act.
Disclosure of Information – Requests for information about another party may be denied unless SBA has the written permission of the individual to release
the information to the requestor or unless the information is subject to disclosure under the Freedom of Information Act. The Privacy Act authorizes SBA
to make certain “routine uses” of information protected by that Act. One such routine use is the disclosure of information maintained in SBA’s system of
records when this information indicates a violation or potential violation of law, whether civil, criminal, or administrative in nature. Specifically, SBA may
refer the information 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 is disclosure to other Federal agencies conducting background
checks but only to the extent the information is relevant to the requesting agencies’ function. See, 74 F.R. 14890 (2009), and as amended from time to time
for additional background and other routine uses. In addition, the CARES Act, requires SBA to register every loan made under the Paycheck Protection
Program using the Taxpayer Identification Number (TIN) assigned to the borrower.
SBA Form 2483-SD (3/21) 6
DocuSign Envelope ID: 3219560E-CE5D-4A77-8B92-95A542985321
Case: 1:23-cv-04875 Document #: 37-1 Filed: 04/14/26 Page 33 of 51 PageID #:196
Paycheck Protection Program
Second Draw Borrower Application Form
Revised March 3, 2021
Debt Collection Act of 1982, Deficit Reduction Act of 1984 (31 U.S.C. 3701 et seq. and other titles) – SBA must obtain your taxpayer identification
number when you apply for a loan. If you receive a loan, and do not make payments as they come due, SBA may: (1) report the status of your loan(s) to
credit bureaus, (2) hire a collection agency to collect your loan, (3) offset your income tax refund or other amounts due to you from the Federal Government,
(4) suspend or debar you or your company from doing business with the Federal Government, (5) refer your loan to the Department of Justice, or (6) take
other action permitted in the loan instruments.
Right to Financial Privacy Act of 1978 (12 U.S.C. 3401) – The Right to Financial Privacy Act of 1978, grants SBA 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
guaranty. SBA is only required 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. SBA’s access rights continue for the term of any approved loan guaranty agreement. SBA is also authorized to transfer to another
Government authority any financial records concerning an approved loan or loan guarantee, as necessary to process, service or foreclose on a loan guaranty
or collect on a defaulted loan guaranty.
Freedom of Information Act (5 U.S.C. 552) – This law provides, with some exceptions, that SBA must supply information reflected in agency files and
records to a person requesting it. Information about approved loans that is generally 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, the amount of the loan, and the type of
the loan. 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.
Occupational Safety and Health Act (15 U.S.C. 651 et seq.) – The Occupational Safety and Health Administration (OSHA) can require businesses to
modify facilities and procedures to protect employees. Businesses that do not comply may be fined and required to abate the hazards in their workplaces.
They may also be ordered to cease operations posing an imminent danger of death or serious injury until employees can be protected. Signing this form is
certification that the applicant, to the best of its knowledge, is in compliance with the applicable OSHA requirements, and will remain in compliance during
the life of the loan.
Civil Rights (13 C.F.R. 112, 113, 117) – All businesses receiving SBA financial 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 112, 113, and 117 of SBA Regulations. All borrowers
must display the "Equal Employment Opportunity Poster" prescribed by SBA.
Equal Credit Opportunity Act (15 U.S.C. 1691) – Creditors are prohibited from discriminating against credit applicants on the basis of race, color, religion,
national origin, sex, marital status or age (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant’s
income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection
Act.
Debarment and Suspension Executive Order 12549 (2 C.F.R. Part 180 and Part 2700) – By submitting this loan application, you certify that neither
the Applicant or any owner of the Applicant have within the past three years been: (a) debarred, suspended, declared ineligible or voluntarily excluded from
participation in a transaction by any Federal 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 owed to the U.S. Government
or its instrumentalities as of the date of execution of this certification.
SBA Form 2483-SD (3/21) 7
DocuSign Envelope ID: 3219560E-CE5D-4A77-8B92-95A542985321
Case: 1:23-cv-04875 Document #: 37-1 Filed: 04/14/26 Page 34 of 51 PageID #:197
PPP Applicant Ownership Sheet
Owner Name Title Ownership % TIN (EIN, SSN) Address
DORA KUZELKA PRESIDENT 51 475361099 250 Roma Jean Pkwy, Streamwood, IL 60107
SBA Form 2483-SD (3/21) 8
DocuSign Envelope ID: 3219560E-CE5D-4A77-8B92-95A542985321
Case: 1:23-cv-04875 Document #: 37-1 Filed: 04/14/26 Page 35 of 51 PageID #:198
PPP Borrower Demographic Information Sheet
Principal Name Position Veteran Gender Race Ethnicity
DORA KUZELKA PRESIDENT 1=Non-Veteran F=Female 5=White N=Not Hispanic or Latino
SBA Form 2483-SD (3/21) 9
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Exhibit D
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Paycheck Protection Program OMB Control No.: 3245-0407
Borrower Application Form Revised March 18, 2021 Expiration Date: 9/30/2021
Check One: Sole proprietor Partnership C-Corp S-Corp LLC DBA or Tradename (if Year of Establishment (if
Independent contractor ( Self-employed
individual applicable) applicable)
501(c)(3) nonprofit 501(c)(6) organization
501(c)(19) veterans organization
Other 501(c) organization Housing cooperative
Tribal business Other ___________________________
Applicant (including affiliates,
Business Legal Name NAICS Code if applicable) Meets Size
Standard (check one):
No more than 500 employees
(or 300 employees, if applicable)
unless “per location” exception
applies
SBA industry size standards
SBA alternative size standard
Business Address (Street, City, State, Zip Code - No P.O. Box addresses Business TIN (EIN, SSN,
Business Phone
allowed) ITIN)
Primary Contact Email Address
x 2.5 + EIDL (Do Not Include
Average Monthly Number of
$ Any EIDL Advance) equals $
Payroll: Employees:
Loan Request Amount:
☐ Covered Operations
☐ Payroll Costs ☐ Rent / Mortgage Interest ☐ Utilities
Purpose of the Expenditures
loan (select all
that apply): ☐ Covered Property ☐ Covered Worker ☐ Other (explain):
☐ Covered Supplier Costs
Damage Protection Expenditures ______________________
Applicant Ownership
List all owners of 20% or more of the equity of the Applicant. Attach a separate sheet if necessary.
Owner Name Title Ownership % TIN (EIN, SSN, Address
ITIN)
PPP Applicant Demographic Information (Optional)
Veteran/gender/race/ethnicity data is collected for program reporting purposes only. Disclosure is voluntary and will have no bearing on the
loan application decision.
Principal Name Principal Position
Select Response Below:
Veteran ☐ Non-Veteran; ☐ Veteran; ☐ Service-Disabled Veteran; ☐ Spouse of Veteran; ☐ Not Disclosed
Gender ☐ Male; ☐ Female; ☐ Not Disclosed
Race (more than 1 ☐ American Indian or Alaska Native; ☐ Asian; ☐ Black or African-American; ☐ Native Hawaiian or Pacific Islander;
may be selected) ☐ White; ☐ Not Disclosed
Ethnicity ☐ Hispanic or Latino; ☐ Not Hispanic or Latino; ☐ Not Disclosed
SBA Form 2483 (3/21) 1
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Paycheck Protection Program
Borrower Application Form Revised March 18, 2021
If questions (1), (2), (5), or (6) are answered “Yes,” the loan will not be approved.
Question Yes No
1. Is the Applicant or any owner of the Applicant presently suspended, debarred, proposed for debarment, declared ineligible,
voluntarily excluded from participation in this transaction by any Federal department or agency, or presently involved in any
bankruptcy?
2. Has the Applicant, any owner of the Applicant, or any business owned or controlled by any of them, ever obtained a direct or
guaranteed loan from SBA or any other Federal agency (other than a Federal student loan made or guaranteed through a program
administered by the Department of Education) that is (a) currently delinquent, or (b) has defaulted in the last 7 years and caused a loss
to the government?
3. Is the Applicant or any owner of the Applicant an owner of any other business, or have common management (including a
management agreement) with any other business? If yes, list all such businesses (including their TINs if available) and describe the
relationship on a separate sheet identified as addendum A.
4. Did the Applicant receive an SBA Economic Injury Disaster Loan between January 31, 2020 and April 3, 2020? If yes, provide
details on a separate sheet identified as addendum B.
5. Is the Applicant (if an individual) or any individual owning 20% or more of the equity of the Applicant presently incarcerated or, for
any felony, presently subject to an indictment, criminal information, arraignment, or other means by which formal criminal charges
are brought in any jurisdiction?
Initial here to confirm your response to question 5 → _____________________
6. Within the last 5 years, for any felony involving fraud, bribery, embezzlement, or a false statement in a loan application or an
application for federal financial assistance, has the Applicant (if an individual) or any owner of the Applicant 1) been convicted; 2)
pleaded guilty; 3) pleaded nolo contendere; or 4) commenced any form of parole or probation (including probation before judgment)?
Initial here to confirm your response to question 6 → _____________________
7. Is the United States the principal place of residence for all employees included in the Applicant’s payroll calculation above?
8. Is the Applicant a franchise?
9. Is the franchise listed in SBA’s Franchise Directory? If yes, enter SBA Franchise Identifier Code here: _______________
SBA Form 2483 (3/21) 2
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Paycheck Protection Program
Borrower Application Form Revised March 18, 2021
By Signing Below, You Make the Following Representations, Authorizations, and Certifications
I certify that:
• I have read the statements included in this form, including the Statements Required by Law and Executive Orders, and I understand them.
• The Applicant is eligible to receive a loan under the rules in effect at the time this application is submitted that have been issued by the Small
Business Administration (SBA) and the Department of the Treasury (Treasury) implementing the Paycheck Protection Program under Division A,
Title I of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), the Economic Aid to Hard-Hit Small Businesses, Nonprofits, and
Venues Act, and Title V of the American Rescue Plan Act of 2021 (the Paycheck Protection Program Rules).
• The Applicant, together with its affiliates (if applicable), (1) is an independent contractor, self-employed individual, or sole proprietor with no
employees; (2) if not a housing cooperative, eligible 501(c)(6) organization, other eligible 501(c) organization, or eligible destination marketing
organization, employs no more than the greater of 500 employees or, if applicable, the size standard in number of employees established by SBA
in 13 C.F.R. 121.201 for the Applicant’s industry; (3) if a housing cooperative, employs no more than 300 employees; (4) if an eligible 501(c)(6)
organization, other eligible 501(c) organization, or eligible destination marketing organization, employs no more than 300 employees per physical
location; (5) if NAICS 72 or a 501(c)(3) organization, employs no more than 500 employees per physical location; (6) if a news organization that
is majority owned or controlled by a NAICS code 511110 or 5151 business, a nonprofit public broadcasting entity with a trade or business under
NAICS code 511110 or 5151, or an Internet-only news or periodical publisher assigned NAICS code 519130 and engaged in the collection and
distribution of local or regional and national news and information, employs no more than 500 employees (or, if applicable, the size standard in
number of employees established by SBA in 13 C.F.R. 121.201 for the Applicant’s industry) per location; or (7) is a small business under the
applicable revenue-based size standard established by SBA in 13 C.F.R. 121.201 for the Applicant’s industry or under the SBA alternative size
standard.
• I will comply, whenever applicable, with the civil rights and other limitations in this form.
• All loan proceeds will be used only for business-related purposes as specified in the loan application and consistent with the Paycheck Protection
Program Rules including the prohibition on using loan proceeds for lobbying activities and expenditures. If Applicant is a news organization that
became eligible for a loan under Section 317 of the Economic Aid to Hard-Hit Small Businesses, Nonprofits, and Venues Act, proceeds of the loan
will be used to support expenses at the component of the business concern that produces or distributes locally focused or emergency information.
If the Applicant is an Internet-only news or periodical publisher that became eligible for a loan under Section 5001 of the American Rescue Plan
Act of 2021, the proceeds of the loan will be used to support expenses at the component of the business or organization that supports local or
regional news.
• I understand that SBA encourages the purchase, to the extent feasible, of American-made equipment and products.
• The Applicant is not engaged in any activity that is illegal under federal, state or local law.
• Any EIDL loan received by the Applicant (Section 7(b)(2) of the Small Business Act) between January 31, 2020 and April 3, 2020 was for a
purpose other than paying payroll costs and other allowable uses for loans under the Paycheck Protection Program Rules.
For Applicants who are individuals: 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 Act, as amended.
The authorized representative of the Applicant must certify in good faith to all of the below by initialing next to each one:
The Applicant was in operation on February 15, 2020, has not permanently closed, and was either an eligible self-employed individual,
independent contractor, or sole proprietorship with no employees, or had employees for whom it paid salaries and payroll taxes or paid independent
contractors, as reported on Form(s) 1099-MISC.
Current economic uncertainty makes this loan request necessary to support the ongoing operations of the Applicant.
The funds will be used to retain workers and maintain payroll; or make payments for mortgage interest, rent, utilities, covered operations
expenditures, covered property damage costs, covered supplier costs, and covered worker protection expenditures as specified under the Paycheck
Protection Program Rules; I understand that if the funds are knowingly used for unauthorized purposes, the federal government may hold me
legally liable, such as for charges of fraud.
I understand that loan forgiveness will be provided for the sum of documented payroll costs, covered mortgage interest payments, covered rent
payments, covered utilities, covered operations expenditures, covered property damage costs, covered supplier costs, and covered worker
protection expenditures, and not more than 40% of the forgiven amount may be for non-payroll costs. If required, the Applicant will provide to
the Lender and/or SBA documentation verifying the number of full-time equivalent employees on the Applicant’s payroll as well as the dollar
amounts of eligible expenses for the covered period following this loan.
The Applicant has not and will not receive another loan under the Paycheck Protection Program, section 7(a)(36) of the Small Business Act (15
U.S.C. 636(a)(36)) (this does not include Paycheck Protection Program second draw loans, section 7(a)(37) of the Small Business Act (15 U.S.C.
636(a)(37)).
The Applicant has not been approved for a Shuttered Venue Operator (SVO) grant from SBA as of the date of this loan application, and the
Applicant acknowledges that if the Applicant is approved for an SVO grant before SBA issues a loan number for this loan, the Applicant is
ineligible for the loan and acceptance of any loan proceeds will be considered an unauthorized use.
_____ The President, the Vice President, the head of an Executive department, or a Member of Congress, or the spouse of such person as determined
under applicable common law, does not directly or indirectly hold a controlling interest in the Applicant, with such terms having the meanings
provided in Section 322 of the Economic Aid to Hard-Hit Small Businesses, Nonprofits, and Venues Act.
_____ The Applicant is not an issuer, the securities of which are listed on an exchange registered as a national securities exchange under section 6 of the
Securities Exchange Act of 1934 (15 U.S.C. 78f).
SBA Form 2483 (3/21) 3
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Paycheck Protection Program
Borrower Application Form Revised March 18, 2021
I further certify that the information provided in this application and the information provided in all supporting documents and forms is true and
accurate in all material respects. I understand that knowingly making a false statement to obtain a guaranteed loan from SBA 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.
I acknowledge that the Lender will confirm the eligible loan amount using required documents submitted. I understand, acknowledge, and agree
that the Lender can share any tax information that I have provided with SBA’s authorized representatives, including authorized representatives of
the SBA Office of Inspector General, for the purpose of compliance with SBA Loan Program Requirements and all SBA reviews.
_________________________________________________________ ________________________
Signature of Authorized Representative of Applicant Date
___________________________________________ ________________________
Print Name Title
SBA Form 2483 (3/21) 4
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Paycheck Protection Program
Borrower Application Form Revised March 18, 2021
Purpose of this form:
This form is to be completed by the authorized representative of the Applicant and submitted to your SBA Participating Lender. Submission of the requested
information is required to make a determination regarding eligibility for financial assistance. Failure to submit the information would affect that
determination.
An Applicant that files an IRS Form 1040, Schedule C, and elects to calculate the PPP loan amount using net profit must use this form. An Applicant that
files an IRS Form 1040, Schedule C, and elects to calculate the PPP loan amount using gross income cannot use this form, and instead must use SBA Form
2483-C. An Applicant that files an IRS Form 1040, Schedule F, and calculates the PPP loan amount using gross income must also use this form.
Instructions for completing this form:
With respect to Purpose of the Loan, payroll costs consist of compensation to employees (whose principal place of residence is the United States) in the
form of salary, wages, commissions, or similar compensation; cash tips or the equivalent (based on employer records of past tips or, in the absence of such
records, a reasonable, good-faith employer estimate of such tips); payment for vacation, parental, family, medical, or sick leave (except those paid leave
amounts for which a credit is allowed under FFCRA Sections 7001 and 7003); allowance for separation or dismissal; payment for the provision of employee
benefits (including insurance premiums) consisting of group health care coverage, group life, disability, vision, or dental insurance, and retirement benefits;
payment of state and local taxes assessed on compensation of employees; and, for an independent contractor or sole proprietor, wage, commissions, income,
or net earnings from self-employment or similar compensation.
For purposes of calculating Average Monthly Payroll, most Applicants will use the average monthly payroll for 2019 or 2020, excluding costs over $100,000
on an annualized basis, as prorated for the period during which the payments are made or the obligation to make the payments is incurred, for each employee.
For seasonal businesses, the Applicant may elect to instead use average total monthly payroll for any twelve-week period selected by the Applicant between
February 15, 2019 and February 15, 2020, excluding costs over $100,000 on an annualized basis, as prorated for the period during which the payments are
made or the obligation to make the payments is incurred, for each employee. For new businesses, average monthly payroll may be calculated using the time
period from January 1, 2020 to February 29, 2020, excluding costs over $100,000 on an annualized basis, as prorated for the period during which the
payments are made or the obligation to make the payments is incurred, for each employee. For farmers and ranchers that operate as a sole proprietorship or
as an independent contractor, or who are eligible self-employed individuals (including single member LLCs and qualified joint ventures) and report farm
income or expenses on a Schedule F (or any equivalent successor IRS form), payroll costs are computed using eligible payroll costs for employees, if any,
plus the lesser of $100,000 and the difference between gross income and any eligible payroll costs for employees, as reported on a Schedule F. For Applicants
that file IRS Form 1040, Schedule C, and elect to calculate the PPP loan amount using net profit, payroll costs are computed using line 31 net profit amount,
limited to $100,000, plus any eligible payroll costs for employees (to calculate loan amount using gross income, see SBA Form 2483-C). For Applicants
that are partnerships, payroll costs are computed using net earnings from self-employment of individual general partners, as reported on IRS Form 1065 K-
1, reduced by section 179 expense deduction claimed, unreimbursed partnership expenses claimed, and depletion claimed on oil and gas properties,
multiplied by 0.9235, that is not more than $100,000, plus any eligible payroll costs for employees.
For Schedule F filers, if the Applicant is a qualified joint venture for federal income tax purposes ((1) the only members of the joint venture are a married
couple who file a joint return and each file Schedule F, (2) both spouses materially participate in the trade or business, and (3) both spouses elect not to be
treated as a partnership), only one spouse may submit this form on behalf of the qualified joint venture.
For purposes of calculating the loan amount using gross income (Schedule F filers only), use the sum of gross income (Schedule F, line 9) from both spouses.
For purposes of reporting Number of Employees, sole proprietors, self-employed individuals, and independent contractors should include themselves as
employees (i.e., the minimum number in the box Number of Employees is one). Applicants may use their average employment over the time period used
to calculate their aggregate payroll costs to determine their number of employees. Alternatively, Applicants may elect to use the average number of
employees per pay period in the 12 completed calendar months prior to the date of the loan application.
For purposes of reporting Year of Establishment, self-employed individuals and independent contractors may enter “NA”.
For purposes of reporting NAICS Code, applicants must match the business activity code provided on their IRS income tax filings, if applicable.
If Applicant is refinancing an Economic Injury Disaster Loan (EIDL): Add the outstanding amount of an EIDL made between January 31, 2020 and April
3, 2020 to Loan Request as indicated on the form. Do not add the amount of any EIDL Advance.
All parties listed below are considered owners of the Applicant:
• For a sole proprietorship, the sole proprietor;
• For a partnership, all general partners, and all limited partners owning 20% or more of the equity of the firm;
• For a corporation, all owners of 20% or more of the corporation;
• For limited liability companies, all members owning 20% or more of the company; and
• Any Trustor (if the Applicant is owned by a trust).
SBA Form 2483 (3/21) 5
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Paycheck Protection Program
Borrower Application Form Revised March 18, 2021
For purposes of reporting (optional) demographic information:
1. Purpose. Veteran/gender/race/ethnicity data is collected for program reporting purposes only.
2. Description. This form requests information about each of the Applicant’s Principals. Add additional sheets if necessary.
3. Definition of Principal. The term “Principal” means:
• For a self-employed individual, independent contractor, or a sole proprietor, the self-employed individual, independent contractor, or sole
proprietor.
• For a partnership, all general partners and all limited partners owning 20% or more of the equity of the Applicant, or any partner that is
involved in the management of the Applicant’s business.
• For a corporation, all owners of 20% or more of the Applicant, and each officer and director.
• For a limited liability company, all members owning 20% or more of the Applicant, and each officer and director.
• Any individual hired by the Applicant to manage the day-to-day operations of the Applicant (“key employee”).
• Any trustor (if the Applicant is owned by a trust).
• For a nonprofit organization, the officers and directors of the Applicant.
4. Principal Name. Insert the full name of the Principal.
5. Principal Position. Identify the Principal’s position; for example, self-employed individual; independent contractor; sole proprietor; general
partner; owner; officer; director; member; or key employee.
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 application, including gathering data needed, is 8 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.
Privacy Act (5 U.S.C. 552a) – Under the provisions of the Privacy Act, you are not required to provide your social security number. Failure to provide your
social security number may not affect any right, benefit or privilege to which you are entitled. (But see Debt Collection Notice regarding taxpayer
identification number below.) Disclosures of name and other personal identifiers are required to provide SBA with sufficient information to make a character
determination. When evaluating character, SBA considers the person’s integrity, candor, and disposition toward criminal actions. Additionally, SBA is
specifically authorized to verify your criminal history, or lack thereof, pursuant to section 7(a)(1)(B), 15 U.S.C. Section 636(a)(1)(B) of the Small Business
Act.
Disclosure of Information – Requests for information about another party may be denied unless SBA has the written permission of the individual to release
the information to the requestor or unless the information is subject to disclosure under the Freedom of Information Act. The Privacy Act authorizes SBA
to make certain “routine uses” of information protected by that Act. One such routine use is the disclosure of information maintained in SBA’s system of
records when this information indicates a violation or potential violation of law, whether civil, criminal, or administrative in nature. Specifically, SBA may
refer the information 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 is disclosure to other Federal agencies conducting background
checks but only to the extent the information is relevant to the requesting agencies’ function. See, 74 F.R. 14890 (2009), and as amended from time to time
for additional background and other routine uses. In addition, the CARES Act, requires SBA to register every loan made under the Paycheck Protection
Program using the Taxpayer Identification Number (TIN) assigned to the borrower.
Debt Collection Act of 1982, Deficit Reduction Act of 1984 (31 U.S.C. 3701 et seq. and other titles) – SBA must obtain your taxpayer identification
number when you apply for a loan. If you receive a loan, and do not make payments as they come due, SBA may: (1) report the status of your loan(s) to
credit bureaus, (2) hire a collection agency to collect your loan, (3) offset your income tax refund or other amounts due to you from the Federal Government,
(4) suspend or debar you or your company from doing business with the Federal Government, (5) refer your loan to the Department of Justice, or (6) take
other action permitted in the loan instruments.
Right to Financial Privacy Act of 1978 (12 U.S.C. 3401) – The Right to Financial Privacy Act of 1978, grants SBA 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
guaranty. SBA is only required 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. SBA’s access rights continue for the term of any approved loan guaranty agreement. SBA is also authorized to transfer to another
Government authority any financial records concerning an approved loan or loan guarantee, as necessary to process, service or foreclose on a loan guaranty
or collect on a defaulted loan guaranty.
Freedom of Information Act (5 U.S.C. 552) – This law provides, with some exceptions, that SBA must supply information reflected in agency files and
records to a person requesting it. Information about approved loans that is generally 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, the amount of the loan, and the type of
the loan. 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.
Occupational Safety and Health Act (15 U.S.C. 651 et seq.) – The Occupational Safety and Health Administration (OSHA) can require businesses to
modify facilities and procedures to protect employees. Businesses that do not comply may be fined and required to abate the hazards in their workplaces.
They may also be ordered to cease operations posing an imminent danger of death or serious injury until employees can be protected. Signing this form is
certification that the applicant, to the best of its knowledge, is in compliance with the applicable OSHA requirements, and will remain in compliance during
the life of the loan.
SBA Form 2483 (3/21) 6
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Paycheck Protection Program
Borrower Application Form Revised March 18, 2021
Civil Rights (13 C.F.R. 112, 113, 117) – All businesses receiving SBA financial 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 112, 113, and 117 of SBA Regulations. All borrowers
must display the "Equal Employment Opportunity Poster" prescribed by SBA.
Equal Credit Opportunity Act (15 U.S.C. 1691) – Creditors are prohibited from discriminating against credit applicants on the basis of race, color, religion,
national origin, sex, marital status or age (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant’s
income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection
Act.
Debarment and Suspension Executive Order 12549 (2 C.F.R. Part 180 and Part 2700) – By submitting this loan application, you certify that neither
the Applicant or any owner of the Applicant have within the past three years been: (a) debarred, suspended, declared ineligible or voluntarily excluded from
participation in a transaction by any Federal 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 owed to the U.S. Government
or its instrumentalities as of the date of execution of this certification.
SBA Form 2483 (3/21) 7
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Exhibit E
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Paycheck Protection Program OMB Control No.: 3245-0417
Second Draw Borrower Application Form Revised February 17, 2021 Expiration Date: 7/31/2021
Check One: Sole proprietor Partnership C-Corp S-Corp LLC DBA or Tradename (if Year of Establishment (if
( Self-employed
Independent contractor individual applicable) applicable)
501(c)(3) nonprofit 501(c)(6) organization
501(c)(19) veterans organization Housing cooperative
Tribal business Other _ ___________________________
Business Legal Name NAICS Code
Business Address (Street, City, State, Zip Code - No P.O. Box addresses Business TIN (EIN, SSN) Business Phone
allowed)
Primary Contact Email Address
x 2.5 (or x 3.5 for NAICS
Number of Employees
Average Monthly 72 applicants) equals Loan
$ $ (including affiliates, if
Payroll: Request Amount (may not
applicable; may not exceed 300):
exceed $2,000,000):
☐Payroll Costs ☐Rent / Mortgage Interest ☐Utilities ☐Covered Operations
Purpose of the Expenditures
loan (select all that
apply): ☐Covered Property ☐Covered Supplier Costs ☐Covered Worker ☐Other (explain):
Damage Protection Expenditures ______________________
PPP First Draw
SBA Loan Number:
Reduction in Gross Receipts of at Least 2020 Quarter Reference Quarter
25% (Applicants for loans of $150,000 or (e.g., 2Q 2020): (e.g., 2Q 2019):
less may leave blank but must provide
upon or before seeking loan forgiveness Gross Receipts: $ Gross Receipts $
or upon SBA request):
Applicant Ownership
List all owners of 20% or more of the equity of the Applicant. Attach a separate sheet if necessary.
Owner Name Title Ownership % TIN (EIN, SSN) Address
PPP Borrower Demographic Information (Optional)
Veteran/gender/race/ethnicity data is collected for program reporting purposes only. Disclosure is voluntary and will have no bearing on the
loan application decision.
Principal Name Position
Select Response Below:
Veteran ☐ Non-Veteran; ☐ Veteran; ☐ Service-Disabled Veteran; ☐ Spouse of Veteran; ☐ Not Disclosed
Gender ☐ Male; ☐ Female; ☐ Not Disclosed
Race (more than 1 may ☐ American Indian or Alaska Native; ☐ Asian; ☐ Black or African-American;
be selected) ☐ Native Hawaiian or Pacific Islander; ☐ White; ☐ Not Disclosed
Ethnicity ☐ Hispanic or Latino; ☐ Not Hispanic or Latino; ☐ Not Disclosed
SBA Form 2483-SD (2/21) 1
Case: 1:23-cv-04875 Document #: 37-1 Filed: 04/14/26 Page 46 of 51 PageID #:209
Paycheck Protection Program
Second Draw Borrower Application Form Revised February 17, 2021
If questions (1), (2), (4), or (5) are answered “Yes,” the loan will not be approved.
Question Yes No
1. Is the Applicant or any owner of the Applicant presently suspended, debarred, proposed for debarment, declared ineligible,
voluntarily excluded from participation in this transaction by any Federal department or agency, or presently involved in any
bankruptcy?
2. Has the Applicant, any owner of the Applicant, or any business owned or controlled by any of them, ever obtained a direct or
guaranteed loan from SBA or any other Federal agency that is (a) currently delinquent, or (b) has defaulted in the last 7 years and
caused a loss to the government?
3. Is the Applicant or any owner of the Applicant an owner of any other business, or have common management (including a
management agreement) with any other business? If yes, list all such businesses (including their TINs if available) and describe the
relationship on a separate sheet identified as addendum A.
4. Is the Applicant (if an individual) or any individual owning 20% or more of the equity of the Applicant presently incarcerated or, for
any felony, presently subject to an indictment, criminal information, arraignment, or other means by which formal criminal charges
are brought in any jurisdiction?
Initial here to confirm your response to question 4 →
5. Within the last 5 years, for any felony involving fraud, bribery, embezzlement, or a false statement in a loan application or an
application for federal financial assistance, or within the last year, for any other felony, has the Applicant (if an individual) or any
owner of the Applicant 1) been convicted; 2) pleaded guilty; 3) pleaded nolo contendere; or 4) commenced any form of parole or
probation (including probation before judgment)?
Initial here to confirm your response to question 5 →
6. Is the United States the principal place of residence for all employees included in the Applicant’s payroll calculation above?
7. Is the Applicant a franchise?
8. Is the franchise listed in SBA’s Franchise Directory? If yes, enter SBA Franchise Identifier Code here: _______________
SBA Form 2483-SD (2/21) 2
Case: 1:23-cv-04875 Document #: 37-1 Filed: 04/14/26 Page 47 of 51 PageID #:210
Paycheck Protection Program
Second Draw Borrower Application Form Revised February 17, 2021
By Signing Below, You Make the Following Representations, Authorizations, and Certifications
I certify that:
• I have read the statements included in this form, including the Statements Required by Law and Executive Orders, and I understand them.
• The Applicant is eligible to receive a loan under the rules in effect at the time this application is submitted that have been issued by the Small
Business Administration (SBA) and the Department of the Treasury (Treasury) implementing Second Draw Paycheck Protection Program Loans
under Division A, Title I of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) and the Economic Aid to Hard-Hit Small
Businesses, Nonprofits, and Venues Act (the Paycheck Protection Program Rules).
• The Applicant, together with its affiliates (if applicable), (1) is an independent contractor, self-employed individual, or sole proprietor with no
employees; (2) employs no more than 300 employees; or (3) if NAICS 72, employs no more than 300 employees per physical location; (4) if a
news organization that is majority owned or controlled by a NAICS code 511110 or 5151 business or a nonprofit public broadcasting entity with
a trade or business under NAICS code 511110 or 5151, employs no more than 300 employees per location.
• I will comply, whenever applicable, with the civil rights and other limitations in this form.
• All loan proceeds will be used only for business-related purposes as specified in the loan application and consistent with the Paycheck Protection
Program Rules including the prohibition on using loan proceeds for lobbying activities and expenditures. If Applicant is a news organization
that became eligible for a loan under Section 317 of the Economic Aid to Hard-Hit Small Businesses, Nonprofits, and Venues Act, proceeds of
the loan will be used to support expenses at the component of the business concern that produces or distributes locally focused or emergency
information.
• I understand that SBA encourages the purchase, to the extent feasible, of American-made equipment and products.
• The Applicant is not engaged in any activity that is illegal under federal, state or local law.
For Applicants who are individuals: 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 Act, as amended.
The authorized representative of the Applicant must certify in good faith to all of the below by initialing next to each one:
The Applicant was in operation on February 15, 2020, has not permanently closed, and was either an eligible self-employed individual,
independent contractor, or sole proprietorship with no employees, or had employees for whom it paid salaries and payroll taxes or paid
independent contractors, as reported on Form(s) 1099-MISC.
Current economic uncertainty makes this loan request necessary to support the ongoing operations of the Applicant.
The Applicant has realized a reduction in gross receipts in excess of 25% relative to the relevant comparison time period. For loans greater
than $150,000, Applicant has provided documentation to the lender substantiating the decline in gross receipts. For loans of $150,000 or
less, Applicant will provide documentation substantiating the decline in gross receipts upon or before seeking loan forgiveness for the Second
Draw Paycheck Protection Program Loan or upon SBA request.
The Applicant received a First Draw Paycheck Protection Program Loan and, before the Second Draw Paycheck Protection Program Loan
is disbursed, will have used the full loan amount (including any increase) of the First Draw Paycheck Protection Program Loan only for
eligible expenses.
The funds will be used to retain workers and maintain payroll; or make payments for mortgage interest, rent, utilities, covered operations
expenditures, covered property damage costs, covered supplier costs, and covered worker protection expenditures as specified under the
Paycheck Protection Program Rules; I understand that if the funds are knowingly used for unauthorized purposes, the federal government
may hold me legally liable, such as for charges of fraud.
I understand that loan forgiveness will be provided for the sum of documented payroll costs, covered mortgage interest payments, covered
rent payments, covered utilities, covered operations expenditures, covered property damage costs, covered supplier costs, and covered worker
protection expenditures, and not more than 40% of the forgiven amount may be for non-payroll costs. If required, the Applicant will provide
to the Lender and/or SBA documentation verifying the number of full-time equivalent employees on the Applicant’s payroll as well as the
dollar amounts of eligible expenses for the covered period following this loan.
_____ The Applicant has not and will not receive another Second Draw Paycheck Protection Program Loan.
The Applicant has not and will not receive a Shuttered Venue Operator grant from SBA.
SBA Form 2483-SD (2/21) 3
Case: 1:23-cv-04875 Document #: 37-1 Filed: 04/14/26 Page 48 of 51 PageID #:211
Paycheck Protection Program
Second Draw Borrower Application Form Revised February 17, 2021
The President, the Vice President, the head of an Executive department, or a Member of Congress, or the spouse of such person as determined
under applicable common law, does not directly or indirectly hold a controlling interest in the Applicant, with such terms having the meanings
provided in Section 322 of the Economic Aid to Hard-Hit Small Businesses, Nonprofits, and Venues Act.
The Applicant is not an issuer, the securities of which are listed on an exchange registered as a national securities exchange under section 6
of the Securities Exchange Act of 1934 (15 U.S.C. 78f).
The Applicant is not a business concern or entity (a) for which an entity created in or organized under the laws of the People’s Republic of
China or the Special Administrative Region of Hong Kong, or that has significant operations in the People’s Republic of China or the Special
Administrative Region of Hong Kong, owns or holds, directly or indirectly, not less than 20 percent of the economic interest of the business
concern or entity, including as equity shares or a capital or profit interest in a limited liability company or partnership; or (b) that retains, as
a member of the board of directors of the business concern, a person who is a resident of the People’s Republic of China.
The Applicant is not required to submit a registration statement under section 2 of the Foreign Agents Registration Act of 1938 (22 U.S.C.
612).
The Applicant is not a business concern or entity primarily engaged in political or lobbying activities, including any entity that is organized
for research or for engaging in advocacy in areas such as public policy or political strategy or otherwise describes itself as a think tank in any
public documents.
I further certify that the information provided in this application and the information provided in all supporting documents and forms is true
and accurate in all material respects. I understand that knowingly making a false statement to obtain a guaranteed loan from SBA 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.
I acknowledge that the Lender will confirm the eligible loan amount using required documents submitted. I understand, acknowledge, and
agree that the Lender can share any tax information that I have provided with SBA’s authorized representatives, including authorized
representatives of the SBA Office of Inspector General, for the purpose of compliance with SBA Loan Program Requirements and all SBA
reviews.
_________________________________________________________ ________________________
Signature of Authorized Representative of Applicant Date
_________________________________________________________ ________________________
Print Name Title
SBA Form 2483-SD (2/21) 4
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Paycheck Protection Program
Second Draw Borrower Application Form Revised February 17, 2021
Purpose of this form:
This form is to be completed by the authorized representative of the Applicant and submitted to your SBA Participating Lender. Submission of the requested
information is required to make a determination regarding eligibility for financial assistance. Failure to submit the information would affect that
determination.
Instructions for completing this form:
With respect to “purpose of the loan,” payroll costs consist of compensation to employees (whose principal place of residence is the United States) in the
form of salary, wages, commissions, or similar compensation; cash tips or the equivalent (based on employer records of past tips or, in the absence of such
records, a reasonable, good-faith employer estimate of such tips); payment for vacation, parental, family, medical, or sick leave (except those paid leave
amounts for which a credit is allowed under FFCRA Sections 7001 and 7003); allowance for separation or dismissal; payment for the provision of employee
benefits consisting of group health care coverage (including insurance premiums), group life, disability, vision, or dental insurance, and retirement benefits;
payment of state and local taxes assessed on compensation of employees; and, for an independent contractor or sole proprietor, wage, commissions, income,
or net earnings from self-employment or similar compensation.
For purposes of calculating “Average Monthly Payroll,” most Applicants will use the average monthly payroll for 2019 or 2020, excluding costs over
$100,000 on an annualized basis, as prorated for the period during which the payments are made or the obligation to make the payments is incurred, for
each employee. For seasonal businesses, the Applicant may elect to instead use average total monthly payroll for any twelve-week period selected by the
Applicant between February 15, 2019 and February 15, 2020, excluding costs over $100,000 on an annualized basis, as prorated for the period during which
the payments are made or the obligation to make the payments is incurred, for each employee. For new businesses without 12 months of payroll costs but
that were in operation on February 15, 2020, average monthly payroll may be calculated based on the number of months in which payroll costs were incurred,
excluding costs over $100,000 on an annualized basis for each employee, as prorated for the period during which the payments are made or the obligation
to make the payments is incurred, for each employee. For farmers and ranchers that operate as a sole proprietorship or as an independent contractor, or who
are eligible self-employed individuals and report farm income or expenses on a Schedule F (or any equivalent successor IRS form), payroll costs are
computed using eligible payroll costs for employees, if any, plus the lesser of $100,000 and the difference between gross income and any eligible payroll
costs for employees, as reported on a Schedule F. For Applicants that file IRS Form 1040, Schedule C, payroll costs are computed using line 31 net profit
amount, limited to $100,000, plus any eligible payroll costs for employees. For Applicants that are partnerships, payroll costs are computed using net
earnings from self-employment of individual general partners, as reported on IRS Form 1065 K-1, reduced by section 179 expense deduction claimed,
unreimbursed partnership expenses claimed, and depletion claimed on oil and gas properties, multiplied by 0.9235, that is not more than $100,000, plus any
eligible payroll costs for employees.
In determining whether the Applicant experienced at least a 25% reduction in gross receipts, for loans above $150,000, the Applicant must identify the 2020
quarter meeting this requirement, identify the reference quarter, and state the gross receipts amounts for both quarters, as well as provide supporting
documentation. For loans of $150,000 and below, these fields are not required and the Applicant only must certify that the Applicant has met the 25% gross
receipts reduction at the time of application; however, upon or before seeking loan forgiveness (or upon SBA request) the Applicant must provide
documentation that identifies the 2020 quarter meeting this requirement, identifies the reference quarter, states the gross receipts amounts for both quarters,
and supports the amounts provided. For all loans, the appropriate reference quarter depends on how long the Applicant has been in operation:
• For all entities other than those satisfying the conditions set forth below, Applicants must demonstrate that gross receipts in any quarter of 2020 were
at least 25% lower than the same quarter of 2019. Alternatively, Applicants may compare annual gross receipts in 2020 with annual gross receipts in
2019; Applicants choosing to use annual gross receipts must enter “Annual” in the 2020 Quarter and Reference Quarter fields and, as required
documentation, must submit copies of annual tax forms substantiating the annual gross receipts reduction.
• For entities not in business during the first and second quarters of 2019 but in operation during the third and fourth quarters of 2019, Applicants must
demonstrate that gross receipts in any quarter of 2020 were at least 25% lower than either the third or fourth quarters of 2019.
• For entities not in business during the first, second, and third quarters of 2019 but in operation during the fourth quarter of 2019, Applicants must
demonstrate that gross receipts in any quarter of 2020 were at least 25% lower than the fourth quarter of 2019.
• For entities not in business during 2019 but in operation on February 15, 2020, Applicants must demonstrate that gross receipts in the second, third, or
fourth quarter of 2020 were at least 25% lower than the first quarter of 2020.
Gross receipts includes all revenue in whatever form received or accrued (in accordance with the entity’s accounting method) from whatever source,
including from the sales of products or services, interest, dividends, rents, royalties, fees, or commissions, reduced by returns and allowances. Generally,
receipts are considered “total income” (or in the case of a sole proprietorship “gross income”) plus “cost of goods sold” and excludes net capital gains or
losses as these terms are defined and reported on IRS tax return forms. Gross receipts do not include the following: taxes collected for and remitted to a
taxing authority if included in gross or total income, such as sales or other taxes collected from customers and excluding taxes levied on the concern or its
employees; proceeds from transactions between a concern and its domestic or foreign affiliates; and amounts collected for another by a travel agent, real
estate agent, advertising agent, conference management service provider, freight forwarder or customs broker. All other items, such as subcontractor costs,
reimbursements for purchases a contractor makes at a customer's request, investment income, and employee-based costs such as payroll taxes, may not be
excluded from gross receipts. Gross receipts of a borrower must be aggregated with gross receipts of its affiliates. For a nonprofit organization, veterans
organization, nonprofit news organization, 501(c)(6) organization, and destination marketing organization, gross receipts has the meaning in section 6033
of the Internal Revenue Code of 1986.
For purposes of reporting Number of Employees, sole proprietors, self-employed individuals, and independent contractors should include themselves as
employees (i.e., the minimum number in the box “Employees” is one). For NAICS 72 or eligible news organizations, applicants may not exceed 300 per
physical location.
For purposes of reporting Year of Establishment, self-employed individuals and independent contractors may enter “NA”.
For purposes of reporting NAICS Code, applicants must match the business activity code provided on their IRS income tax filings, if applicable. For
purposes of calculating an Applicant’s maximum payroll costs, an Applicant may multiply its average monthly payroll costs by 3.5 only if the Applicant is
in the Accommodation and Food Services sector and has reported a NAICS code beginning with 72 as its business activity code on its most recent IRS
income tax return.
SBA Form 2483-SD (2/21) 5
Case: 1:23-cv-04875 Document #: 37-1 Filed: 04/14/26 Page 50 of 51 PageID #:213
Paycheck Protection Program
Second Draw Borrower Application Form Revised February 17, 2021
All parties listed below are considered owners of the Applicant:
• For a sole proprietorship, the sole proprietor;
• For a partnership, all general partners, and all limited partners owning 20% or more of the equity of the firm;
• For a corporation, all owners of 20% or more of the corporation;
• For limited liability companies, all members owning 20% or more of the company; and
• Any Trustor (if the Applicant is owned by a trust).
For purposes of reporting (optional) demographic information:
1. Purpose. Veteran/gender/race/ethnicity data is collected for program reporting purposes only.
2. Description. This form requests information about each of the Borrower’s Principals. Add additional sheets if necessary.
3. Definition of Principal. The term “Principal” means:
• For a self-employed individual, independent contractor, or a sole proprietor, the self-employed individual, independent contractor, or sole
proprietor.
• For a partnership, all general partners and all limited partners owning 20% or more of the equity of the Borrower, or any partner that is
involved in the management of the Borrower’s business.
• For a corporation, all owners of 20% or more of the Borrower, and each officer and director.
• For a limited liability company, all members owning 20% or more of the Borrower, and each officer and director.
• Any individual hired by the Borrower to manage the day-to-day operations of the Borrower (“key employee”).
• Any trustor (if the Borrower is owned by a trust).
• For a nonprofit organization, the officers and directors of the Borrower.
4. Principal Name. Insert the full name of the Principal.
5. Position. Identify the Principal’s position; for example, self-employed individual; independent contractor; sole proprietor; general partner; owner;
officer; director; member; or key employee.
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 application, including gathering data needed, is 8 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.
Privacy Act (5 U.S.C. 552a) – Under the provisions of the Privacy Act, you are not required to provide your social security number. Failure to provide your
social security number may not affect any right, benefit or privilege to which you are entitled. (But see Debt Collection Notice regarding taxpayer
identification number below.) Disclosures of name and other personal identifiers are required to provide SBA with sufficient information to make a character
determination. When evaluating character, SBA considers the person’s integrity, candor, and disposition toward criminal actions. Additionally, SBA is
specifically authorized to verify your criminal history, or lack thereof, pursuant to section 7(a)(1)(B), 15 USC Section 636(a)(1)(B) of the Small Business
Act.
Disclosure of Information – Requests for information about another party may be denied unless SBA has the written permission of the individual to release
the information to the requestor or unless the information is subject to disclosure under the Freedom of Information Act. The Privacy Act authorizes SBA
to make certain “routine uses” of information protected by that Act. One such routine use is the disclosure of information maintained in SBA’s system of
records when this information indicates a violation or potential violation of law, whether civil, criminal, or administrative in nature. Specifically, SBA may
refer the information 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 is disclosure to other Federal agencies conducting background
checks but only to the extent the information is relevant to the requesting agencies’ function. See, 74 F.R. 14890 (2009), and as amended from time to time
for additional background and other routine uses. In addition, the CARES Act, requires SBA to register every loan made under the Paycheck Protection
Program using the Taxpayer Identification Number (TIN) assigned to the borrower.
Debt Collection Act of 1982, Deficit Reduction Act of 1984 (31 U.S.C. 3701 et seq. and other titles) – SBA must obtain your taxpayer identification
number when you apply for a loan. If you receive a loan, and do not make payments as they come due, SBA may: (1) report the status of your loan(s) to
credit bureaus, (2) hire a collection agency to collect your loan, (3) offset your income tax refund or other amounts due to you from the Federal Government,
(4) suspend or debar you or your company from doing business with the Federal Government, (5) refer your loan to the Department of Justice, or (6) take
other action permitted in the loan instruments.
Right to Financial Privacy Act of 1978 (12 U.S.C. 3401) – The Right to Financial Privacy Act of 1978, grants SBA 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
guaranty. SBA is only required 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. SBA’s access rights continue for the term of any approved loan guaranty agreement. SBA is also authorized to transfer to another
Government authority any financial records concerning an approved loan or loan guarantee, as necessary to process, service or foreclose on a loan guaranty
or collect on a defaulted loan guaranty.
Freedom of Information Act (5 U.S.C. 552) – This law provides, with some exceptions, that SBA must supply information reflected in agency files and
records to a person requesting it. Information about approved loans that is generally 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, the amount of the loan, and the type of
the loan. 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.
SBA Form 2483-SD (2/21) 6
Case: 1:23-cv-04875 Document #: 37-1 Filed: 04/14/26 Page 51 of 51 PageID #:214
Paycheck Protection Program
Second Draw Borrower Application Form Revised February 17, 2021
Occupational Safety and Health Act (15 U.S.C. 651 et seq.) – The Occupational Safety and Health Administration (OSHA) can require businesses to
modify facilities and procedures to protect employees. Businesses that do not comply may be fined and required to abate the hazards in their workplaces.
They may also be ordered to cease operations posing an imminent danger of death or serious injury until employees can be protected. Signing this form is
certification that the applicant, to the best of its knowledge, is in compliance with the applicable OSHA requirements, and will remain in compliance during
the life of the loan.
Civil Rights (13 C.F.R. 112, 113, 117) – All businesses receiving SBA financial 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 112, 113, and 117 of SBA Regulations. All borrowers
must display the "Equal Employment Opportunity Poster" prescribed by SBA.
Equal Credit Opportunity Act (15 U.S.C. 1691) – Creditors are prohibited from discriminating against credit applicants on the basis of race, color, religion,
national origin, sex, marital status or age (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant’s
income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection
Act.
Debarment and Suspension Executive Order 12549 (2 C.F.R. Part 180 and Part 2700) – By submitting this loan application, you certify that neither
the Applicant or any owner of the Applicant have within the past three years been: (a) debarred, suspended, declared ineligible or voluntarily excluded from
participation in a transaction by any Federal 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 owed to the U.S. Government
or its instrumentalities as of the date of execution of this certification.
SBA Form 2483-SD (2/21) 7File and source
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