Full text
1
SBA Form 2483 (06/20)
(
Paycheck Protection Program
Borrower Application Form –
Revised June 12, 2020
OMB Control No.: 3245-0407
Expiration Date: 10/31/2020
Check One:
Sole proprietor Partnership C-Corp S-Corp LLC
Independent contractor Eligible self-employed individual
501(c)(3) nonprofit 501(c)(19) veterans organization
Tribal business (sec. 31(b)(2)(C) of Small Business Act) Other
DBA or Tradename if Applicable
N/A
Business Legal Name
Dituri Construction LLC
Business Address
Business TIN (EIN, SSN)
Business Phone
4700 36th Ave SW
Seattle,
WA,
98126
8508
2069384291
Primary Contact
Email Address
Eric Shibley
shibley98126@gmail.com
Average Monthly Payroll:
$130,640.00
x 2.5 + EIDL, Net
of Advance (if
Applicable) Equals
Loan Request:
$326,600.00
Number of
Employees:
49
Purpose of the loan
(select more than one):
☐ Payroll ☐Lease / Mortgage Interest ☐Utilities ☐Other (explain):
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
Eric Shibley
Manager
90.000%
5264
4700 36th Ave SW
Seattle, WA 98126
If questions (1) or (2) below 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 currently delinquent or 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 with, any
other business? If yes, list all such businesses and describe the relationship on a separate sheet identified as addendum A.
4.
Has the Applicant received 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.
If questions (5) or (6) are answered “Yes,” the loan will not be approved.
Question
Yes
No
5.
Is the Applicant (if an individual) or any individual owning 20% or more of the equity of
the Applicant subject to an indictment, criminal information, arraignment, or other means
by which formal criminal charges are brought in any jurisdiction, or presently
incarcerated, or on probation or parole?
Initial here to confirm your response to question 5 → _________
U.S. v. Shibley
CR20-174 JCC
Government Exhibit No. 17
Admitted ________________
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 1 of 38
2
SBA Form 2483 (06/20)
6.
Within the last 5 years, for any felony, has the Applicant (if an individual) or any owner of
the Applicant 1) been convicted; 2) pleaded guilty; 3) pleaded nolo contendere; 4) been
placed on pretrial diversion; or 5) been placed on 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 of the Applicant
included in the Applicant’s payroll calculation above?
8.
Is the Applicant a franchise that is listed in the SBA’s Franchise Directory?
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 2 of 38
Paycheck Protection Program
Borrower Application Form – Revised June 12, 2020
2
SBA Form 2483 (06/20)
By Signing Below, You Make the Following Representations, Authorizations, and Certifications
CERTIFICATIONS AND AUTHORIZATIONS
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) implementing the Paycheck Protection Program under Division A, Title I of the Coronavirus
Aid, Relief, and Economic Security Act (CARES Act) (the Paycheck Protection Program Rule).
•
The Applicant (1) is an independent contractor, eligible self-employed individual, or sole proprietor or (2) employs no more than the
greater of 500 or employees or, if applicable, the size standard in number of employees established by the SBA in 13 C.F.R. 121.201
for the Applicant’s industry.
•
I will comply, whenever applicable, with the civil rights and other limitations in this form.
•
All SBA loan proceeds will be used only for business-related purposes as specified in the loan application and consistent with the
Paycheck Protection Program Rule.
•
To the extent feasible, I will purchase only American-made equipment and products.
•
The Applicant is not engaged in any activity that is illegal under federal, state or local law.
•
Any loan received by the Applicant under 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 loans under the Paycheck Protection Program Rule.
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.
CERTIFICATIONS
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 and 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 mortgage interest payments, lease payments, and utility payments,
as specified under the Paycheck Protection Program Rule; 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.
The Applicant will provide to the Lender documentation verifying the number of full-time equivalent employees on the Applicant’s
payroll as well as the dollar amounts of payroll costs, covered mortgage interest payments, covered rent payments, and covered utilities
for the 24-week period following this loan.
I understand that loan forgiveness will be provided for the sum of documented payroll costs, covered mortgage interest payments,
covered rent payments, and covered utilities, and not more than 40% of the forgiven amount may be for non-payroll costs.
During the period beginning on February 15, 2020 and ending on December 31, 2020, the Applicant has not and will not receive another
loan under the Paycheck Protection Program.
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 USC 1001 and 3571 by imprisonment of not more than five years and/or a fine
of up to $250,000; under 15 USC 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 USC 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
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 3 of 38
Paycheck Protection Program
Borrower Application Form – Revised June 12, 2020
3
SBA Form 2483 (06/20)
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; allowance for separation or dismissal; payment for the provision of employee benefits consisting of group health care coverage,
including insurance premiums, and retirement; 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, excluding costs over
$100,000 on an annualized basis for each employee. For seasonal businesses, the Applicant may elect to instead use average monthly payroll
for the time period between February 15, 2019 and June 30, 2019 or any 12-week period between May 1, 2019 and September 15, 2019,
excluding costs over $100,000 on an annualized basis 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 for each employee.
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, less the amount of any “advance” under an EIDL COVID-19 loan, to Loan Request as indicated on the form.
All parties listed below are considered owners of the Applicant as defined in 13 CFR § 120.10, as well as “principals”:
• 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).
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 (the 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 Act 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) foreclose on collateral or 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
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 4 of 38
Paycheck Protection Program
Borrower Application Form – Revised June 12, 2020
4
SBA Form 2483 (06/20)
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) – Subject to certain exceptions, SBA must supply information reflected in agency files and
records to a person requesting it. Information about approved loans that will be automatically released includes, among other things, statistics
on our loan programs (individual borrowers are not identified in the statistics) and other information such as the names of the borrowers (and
their officers, directors, stockholders or partners), the collateral pledged to secure the loan, the amount of the loan, its purpose in general terms
and the maturity. Proprietary data on a borrower would not routinely be made available to third parties. All requests under this Act are to be
addressed to the nearest SBA office and be identified as a Freedom of Information request.
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, forced to cease operations,
or prevented from starting operations. 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 CFR 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.
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 5 of 38
DOJ-01-0000001758
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 6 of 38
DOJ-01-0000001759
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 7 of 38
DOJ-01-0000001905
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 8 of 38
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 9 of 38
Paycheck Protection Program
Borrower Application Form
1
SBA Form 2483 (04/20)
܆
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(
܆܆
܆܆
܆܆
܆܆
܆
܆
܆
܆
܆
܆
Check One:
Sole proprietor Partnership C-Corp S-Corp LLC
Independent contractor Eligible self-employed individual
501(c)(3) nonprofit 501(c)(19) veterans organization
Tribal business (sec. 31(b)(2)(C) of Small Business Act) Other
DBA or Tradename if Applicable
Business Legal Name
Business Address
Business TIN (EIN, SSN)
Business Phone
( ) -
Primary Contact
Email Address
Average Monthly Payroll:
$
x 2.5 + EIDL, Net of
Advance (if Applicable)
Equals Loan Request:
$
Number of Employees:
Purpose of the loan
(select more than one):
܆Payroll տLease / Mortgage Interest տUtilities տOther (explain):__________________
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
If questions (1) or (2) below 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 currently delinquent or 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 with, any other
business? If yes, list all such businesses and describe the relationship on a separate sheet identified as addendum A.
4.
Has the Applicant received 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.
If questions (5) or (6) are answered “Yes,” the loan will not be approved.
Question
Yes
No
5.
Is the Applicant (if an individual) or any individual owning 20% or more of the equity of the Applicant subject
to an indictment, criminal information, arraignment, or other means by which formal criminal charges are
brought in any jurisdiction, or presently incarcerated, or on probation or parole?
Initial here to confirm your response to question 5 ĺ
6.
Within the last 5 years, for any felony, has the Applicant (if an individual) or any owner of the Applicant 1)
been convicted; 2) pleaded guilty; 3) pleaded nolo contendere; 4) been placed on pretrial diversion; or 5) been
placed on any form of parole or probation (including probation before judgment)?
Initial here to confirm your response to question 6 ĺ
7.
Is the United States the principal place of residence for all employees of the Applicant included in the
Applicant’s payroll calculation above?
8.
Is the Applicant a franchise that is listed in the SBA’s Franchise Directory?
OMB Control No.: 3245-0407
Expiration Date: 09/30/2020
■
ES1 LLC
4700 36th Ave SW Seattle,WA 98126
5849
2069384291
Eric SHibley
ers98126@gmail.com
38,300
95,750
6
■
■
■
■
employee benefits
Eric R Shibley
Manager
100
-5264700 36th Ave SW Seattle W
■
■
■
■
■
ers
■
ers
■
■
U.S. v. Shibley
CR20-174 JCC
Government Exhibit No. 18
Admitted ________________
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 10 of 38
Paycheck Protection Program
Borrower Application Form
2
SBA Form 2483 (04/20)
By Signing Below, You Make the Following Representations, Authorizations, and Certifications
CERTIFICATIONS AND AUTHORIZATIONS
I certify that:
x
I have read the statements included in this form, including the Statements Required by Law and Executive Orders, and I understand them.
x
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) implementing the Paycheck Protection Program under Division A, Title I of the Coronavirus
Aid, Relief, and Economic Security Act (CARES Act) (the Paycheck Protection Program Rule).
x
The Applicant (1) is an independent contractor, eligible self-employed individual, or sole proprietor or (2) employs no more
than the greater of 500 or employees or, if applicable, the size standard in number of employees established by the SBA in 13
C.F.R. 121.201 for the Applicant’s industry.
x
I will comply, whenever applicable, with the civil rights and other limitations in this form.
x
All SBA loan proceeds will be used only for business-related purposes as specified in the loan application and consistent with the
Paycheck Protection Program Rule.
x
To the extent feasible, I will purchase only American-made equipment and products.
x
The Applicant is not engaged in any activity that is illegal under federal, state or local law.
x
Any loan received by the Applicant under 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 loans under the Paycheck Protection Program Rule.
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.
CERTIFICATIONS
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 and 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 mortgage interest payments, lease payments, and utility payments,
as specified under the Paycheck Protection Program Rule; 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.
_____
The Applicant will provide to the Lender documentation verifying the number of full-time equivalent employees on the Applicant’s
payroll as well as the dollar amounts of payroll costs, covered mortgage interest payments, covered rent payments, and covered utilities
for the eight-week period following this loan.
_____
I understand that loan forgiveness will be provided for the sum of documented payroll costs, covered mortgage interest payments,
covered rent payments, and covered utilities, and not more than 25% of the forgiven amount may be for non-payroll costs.
_____
During the period beginning on February 15, 2020 and ending on December 31, 2020, the Applicant has not and will not receive another
loan under the Paycheck Protection Program.
_____
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 USC 1001 and 3571 by imprisonment of not more than five years and/or a
fine of up to $250,000; under 15 USC 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 USC 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
ers
ers
ers
ers
ers
ers
ers
ers
Eric Ryan Shibley
Digitally signed by Eric Ryan Shibley
Date: 2020.04.15 19:08:46 -07'00'
04/15/2020
Eric R Shibley
04/15/2020
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 11 of 38
Paycheck Protection Program
Borrower Application Form
3
SBA Form 2483 (04/20)
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; allowance for separation or dismissal; payment for the provision of employee benefits consisting of group health care coverage,
including insurance premiums, and retirement; 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, excluding costs over
$100,000 on an annualized basis for each employee. For seasonal businesses, the Applicant may elect to instead use average monthly payroll
for the time period between February 15, 2019 and June 30, 2019, excluding costs over $100,000 on an annualized basis 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 for each employee.
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, less the amount of any “advance” under an EIDL COVID-19 loan, to Loan Request as indicated on the form.
All parties listed below are considered owners of the Applicant as defined in 13 CFR § 120.10, as well as “principals”:
x For a sole proprietorship, the sole proprietor;
x For a partnership, all general partners, and all limited partners owning 20% or more of the equity of the firm;
x For a corporation, all owners of 20% or more of the corporation;
x For limited liability companies, all members owning 20% or more of the company; and
x Any Trustor (if the Applicant is owned by a trust).
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.
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 (the 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 Act 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) foreclose on collateral or 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
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 12 of 38
Paycheck Protection Program
Borrower Application Form
4
SBA Form 2483 (04/20)
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) – Subject to certain exceptions, SBA must supply information reflected in agency files and
records to a person requesting it. Information about approved loans that will be automatically released includes, among other things, statistics
on our loan programs (individual borrowers are not identified in the statistics) and other information such as the names of the borrowers (and
their officers, directors, stockholders or partners), the collateral pledged to secure the loan, the amount of the loan, its purpose in general terms
and the maturity. Proprietary data on a borrower would not routinely be made available to third parties. All requests under this Act are to be
addressed to the nearest SBA office and be identified as a Freedom of Information request.
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, forced to cease operations,
or prevented from starting operations. 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 CFR 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.
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 13 of 38
DOJ-01-0000001811
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DOJ-01-0000001812
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DOJ-01-0000001906
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DOJ-01-0000001907
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DOJ-01-0000001837
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Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 19 of 38
1
SBA Form 2483 (04/20)
(
Paycheck Protection Program
Borrower Application Form
OMB Control No.: 3245-0407
Expiration Date: 09/30/2020
Check One:
Sole proprietor Partnership C-Corp S-Corp _ LLC
Independent contractor Eligible self-employed individual
501(c)(3) nonprofit 501(c)(19) veterans organization
Tribal business (sec. 31(b)(2)(C) of Small Business Act) Other
DBA or Tradename if Applicable
N/A
Business Legal Name
Eric r Shibley MD PLLC
Business Address
Business TIN (EIN, SSN)
Business Phone
4700 36th Ave SW
Seattle,
WA,
98126
9052
2069384291
Primary Contact
Email Address
Eric Shibley
shibleymedical@outlook.c
om
Average Monthly Payroll:
$37,560.00
x 2.5 + EIDL, Net
of Advance (if
Applicable) Equals
Loan Request:
$93,900.00
Number of
Employees:
6
Purpose of the loan
(select more than one):
X Payroll ☐Lease / Mortgage Interest ☐Utilities ☐Other (explain):
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
Eric Shibley
Manager
100.000%
5264
4700 36th Ave SW
Seattle, WA 98126
If questions (1) or (2) below 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?
6
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 currently delinquent or has defaulted in the last 7
years and caused a loss to the government?
6
3.
Is the Applicant or any owner of the Applicant an owner of any other business, or have common management with, any
other business? If yes, list all such businesses and describe the relationship on a separate sheet identified as addendum A.
6
4.
Has the Applicant received 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.
6
If questions (5) or (6) are answered “Yes,” the loan will not be approved.
Question
Yes
No
5.
Is the Applicant (if an individual) or any individual owning 20% or more of the equity of
the Applicant subject to an indictment, criminal information, arraignment, or other means
by which formal criminal charges are brought in any jurisdiction, or presently
6
U.S. v. Shibley
CR20-174 JCC
Government Exhibit No. 19
Admitted ________________
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 20 of 38
2
SBA Form 2483 (04/20)
incarcerated, or on probation or parole?
Initial here to confirm your response to question 5 → _________
6.
Within the last 5 years, for any felony, has the Applicant (if an individual) or any owner of
the Applicant 1) been convicted; 2) pleaded guilty; 3) pleaded nolo contendere; 4) been
placed on pretrial diversion; or 5) been placed on any form of parole or probation
(including probation before judgment)?
Initial here to confirm your response to question 6 → _________
6
7.
Is the United States the principal place of residence for all employees of the Applicant
included in the Applicant’s payroll calculation above?
6
8.
Is the Applicant a franchise that is listed in the SBA’s Franchise Directory?
6
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 21 of 38
Paycheck Protection
Program
2
SBA Form 2483 (04/20)
By Signing Below, You Make the Following Representations, Authorizations, and Certifications
CERTIFICATIONS AND AUTHORIZATIONS
I certify that:
x
I have read the statements included in this form, including the Statements Required by Law and Executive Orders, and I understand them.
x
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) implementing the Paycheck Protection Program under Division A, Title I of the Coronavirus
Aid, Relief, and Economic Security Act (CARES Act) (the Paycheck Protection Program Rule).
x
The Applicant (1) is an independent contractor, eligible self-employed individual, or sole proprietor or (2) employs no more
than the greater of 500 or employees or, if applicable, the size standard in number of employees established by the SBA in 13
C.F.R. 121.201 for the Applicant’s industry.
x
I will comply, whenever applicable, with the civil rights and other limitations in this form.
x
All SBA loan proceeds will be used only for business-related purposes as specified in the loan application and consistent with the
Paycheck Protection Program Rule.
x
To the extent feasible, I will purchase only American-made equipment and products.
x
The Applicant is not engaged in any activity that is illegal under federal, state or local law.
x
Any loan received by the Applicant under 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 loans under the Paycheck Protection Program Rule.
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.
CERTIFICATIONS
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 and 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 mortgage interest payments, lease payments, and utility payments,
as specified under the Paycheck Protection Program Rule; 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.
The Applicant will provide to the Lender documentation verifying the number of full-time equivalent employees on the Applicant’s
payroll as well as the dollar amounts of payroll costs, covered mortgage interest payments, covered rent payments, and covered utilities
for the eight-week period following this loan.
I understand that loan forgiveness will be provided for the sum of documented payroll costs, covered mortgage interest payments,
covered rent payments, and covered utilities, and not more than 25% of the forgiven amount may be for non-payroll costs.
During the period beginning on February 15, 2020 and ending on December 31, 2020, the Applicant has not and will not receive another
loan under the Paycheck Protection Program.
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 USC 1001 and 3571 by imprisonment of not more than five years and/or a fine
of up to $250,000; under 15 USC 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 USC 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
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 22 of 38
Paycheck Protection
Program
3
SBA Form 2483 (04/20)
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 thatdetermination.
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; allowance for separation or dismissal; payment for the provision of employee benefits consisting of group health care coverage,
including insurance premiums, and retirement; 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, excluding costs over
$100,000 on an annualized basis for each employee. For seasonal businesses, the Applicant may elect to instead use average monthly payroll
for the time period between February 15, 2019 and June 30, 2019, excluding costs over $100,000 on an annualized basis 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 for each employee.
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, less the amount of any “advance” under an EIDL COVID-19 loan, to Loan Request as indicated on the form.
All parties listed below are considered owners of the Applicant as defined in 13 CFR § 120.10, as well as “principals”:
x For a sole proprietorship, the sole proprietor;
x For a partnership, all general partners, and all limited partners owning 20% or more of the equity of the firm;
x For a corporation, all owners of 20% or more of the corporation;
x For limited liability companies, all members owning 20% or more of the company; and
x Any Trustor (if the Applicant is owned by a trust).
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.
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 (the 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 Act 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) foreclose on collateral or 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
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 23 of 38
Paycheck Protection
Program
4
SBA Form 2483 (04/20)
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) – Subject to certain exceptions, SBA must supply information reflected in agency files and
records to a person requesting it. Information about approved loans that will be automatically released includes, among other things, statistics
on our loan programs (individual borrowers are not identified in the statistics) and other information such as the names of the borrowers (and
their officers, directors, stockholders or partners), the collateral pledged to secure the loan, the amount of the loan, its purpose in general terms
and the maturity. Proprietary data on a borrower would not routinely be made available to third parties. All requests under this Act are to be
addressed to the nearest SBA office and be identified as a Freedom of Information request.
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, forced to cease operations,
or prevented from starting operations. 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 CFR 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.
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 24 of 38
Paycheck Protection Program
Note
© 2020 Farleigh Wada Witt. All rights reserved.
April 2020 - 1
Borrower agrees to the following terms of this Paycheck Protection Program Note (Note) for this Loan.
Lender: Idaho Central Credit Union, 4400 Central Way Pocatello, ID 83202
Date
5/14/20
SBA Loan No.
2071257409
SBA Loan Name
Eric r Shibley MD PLLC
SBA Approval Date
5/5/2020
Borrower Name
Eric r Shibley MD PLLC
Borrower Authorized
Representative
Eric Shibley
Borrower Address
4700 36th Ave SW
Seattle, WA, 98126
Principal Amount
$ 93,900.00
Interest Rate
1.00%
First Payment Due Date
12/14/2020
Payment Amount
5,284.35
Maturity Date
5/14/2022
ICCU Loan Number
724774321
Note Terms
1.
Promise to Pay. Borrower promises to pay to Lender, or order, in lawful money of the United States of America, the principal
amount set forth above or so much as may be outstanding, together with interest on the unpaid principal with interest thereon at the
rates specified below.
2.
Interest Rate and Calculation Method. The unpaid principal balance of this Loan will bear interest at an annual rate as set forth
above. Interest on this Loan is computed on a 365/365 simple interest basis; that is by applying the ratio of the interest rate over the
number of days in a year (365 for all years, including leap years), multiplied by the outstanding principal balance, multiplied by the
actual number of days the principal balance is outstanding. All interest payable under this Loan is computed using this method.
3.
Payments. Borrower will not be required to make any payments under this Note between the date hereof and the First Payment
Date. Borrower will then pay regular monthly payments of principal and interest as set forth above beginning on the First Payment
Date set forth above with all subsequent payments due on the same day of each month after that and a final payment of all unpaid
principal, interest, and any other charges due and payable on the Maturity Date set forth above. Borrower will pay Lender at Lender’s
address shown above or at such other place as Lender may designate in writing. Unless otherwise agreed or required by applicable
law, payments will be applied first to any accrued unpaid interest; then to principal; then to any late charges; and then to any unpaid
collection costs. Borrower authorizes Lender to collect all interest, principal, fees and other sums, if any, due hereunder from time to
time by charging Borrower's deposit account with Lender, or any other deposit account maintained by Borrower with Lender, for the
full amount thereof. Should there be insufficient funds in any such deposit account to pay all such sums when due, the full amount of
such deficiency shall be immediately due and payable by Borrower.
4.
Eligibility for Forgiveness of Loan. Borrower has applied to Lender for a loan from Lender under Section 1102 of the
Coronavirus Aid, Relief, and Economic Security Act (the “CARES Act”) which added a new product, titled “Paycheck Protection
Program” (the “Program”), to the U.S Small Business Administration’s (“SBA’s”) 7(a) Loan Program. Section 1106 of the CARES Act
provides for forgiveness of up to the full principal amount of qualifying loans guaranteed under the Program. The amount of loan
forgiveness will be determined in accordance with and subject to the CARES Act and the rules and regulations promulgated
thereunder. If all of the loan is forgiven, then Borrower’s obligation to repay this Note terminates. If only a part of the loan is forgiven,
then Borrower remains obligated to pay the amount not forgiven. Borrower understands and agrees that Lender cannot guarantee that
all of the loan will be forgiven. Borrower acknowledges that even if all of the loan proceeds are used as permitted by the CARES Act
and the SBA’s Program rules, some portion of the loan may not be eligible for forgiveness. Borrower is solely responsible for
understanding the requirements for, and limitations of, forgiveness under the CARES Act and the SBA’s Program rules as applied to
Borrower’s circumstance. Borrower is not relying on any written or oral representation or statement made by Lender in connection
loan forgiveness criteria and limitations.
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 25 of 38
Paycheck Protection Program Note
© 2020 Farleigh Wada Witt. All rights reserved.
April 2020 - 2
5.
Use of Proceeds. Borrower shall use the loan proceeds strictly in accordance with CARES Act and the rules and regulations
promulgated thereunder. Borrower acknowledges that, if Borrower uses the loan proceeds for unauthorized purposes, then the SBA
may direct Borrower to repay these amounts and Borrower may be subject to additional liability such as charges for fraud. Borrower
also acknowledges that, if any of Borrower’s shareholders, members, or partners use the loan proceeds for unauthorized purposes,
then the SBA may have recourse against them.
6.
Borrower Certifications. Borrower understands and agrees that Lender is relying on the representations, warranties,
certifications, and authorizations in Borrower’s completed Paycheck Protection Program Borrower Application Form (SBA Form 2483)
in making this loan to Borrower to determine, among other things, Borrower’s eligibility for the loan and the use of the loan proceeds.
Borrower also understand and agrees that Lender is relying on the documents that Borrower provided to it (and shall provide
subsequently) to determine the qualifying loan amount and eligibility for loan forgiveness.
7.
Cares Act Compliance And Conforming Amendments. If any provision of this Note conflicts with any of the term of the terms
for loans under Section 1102 of the CARES Act, or with a regulation or program requirement issued by the SBA pursuant to the CARES
Act, the provisions of the CARES Act and the SBA regulations issued thereunder shall control. In addition, Borrower agrees that if a
federal law or an SBA regulation or SBA program requirement issued under the CARES Act after the date of this Note conflicts with
the terms of this Note, the terms of this Note shall be automatically amended to conform to such law or regulation. Lender shall notify
Borrower as soon as reasonably possible on learning of such a change in law or regulation.
8.
Prepayment. Borrower agrees that all loan fees and other prepaid finance charges are earned fully as of the date of the loan and
will not be subject to refund upon early payment (whether voluntary or as a result of default), except as otherwise required by law.
Borrower may prepay a part or all of the unpaid principal amount at any time. Early payments will not, unless agreed to by Lender in
writing, relieve Borrower of Borrower’s obligation to continue to make payments under the payment schedule. Rather, they will reduce
the principal balance due and may result in Borrower’s making fewer payments. Borrower agrees not to send Lender payments
marked “paid in full”, “without recourse”, or similar language. If Borrower sends such a payment, Lender may accept it without losing
any of Lender’s rights under this Note, and Borrower will remain obligated to pay any further amount owed to Lender. All written
communications concerning disputed amounts, including any check or other payment instrument that indicates that the payment
constitutes “payment in full” of the amount owed or that is tendered with other conditions or limitations or as full satisfaction of a
disputed amount must be mailed or delivered to Lender at the address set forth above.
9.
Default. Each of the following shall constitute an event of default (“Event of Default”) under this Note:
Payment Default. Borrower fails to make any payment when due under this Note.
Other Defaults. Borrower, or any party obligated therein, fails to comply with or to perform any other term, obligation, covenant
or condition contained in any of the documents executed in connection with this Note and such failure is not remedied within any grace
period provided therein. Borrower fails to comply with or to perform any term or obligation in any other loan or agreement with another
creditor, if Lender believes the default may materially affect Borrower’s ability to pay this Note.
Compliance Default. Failure of Borrower to comply with any other term, obligation, covenant or condition contained in this
Note, including without limitation the failure of Borrower to use the loan proceeds strictly in accordance with the CARES Act and the
rules and regulations promulgated thereunder.
Default in Favor of Third Parties. Should Borrower default under any loan, extension of credit, security agreement, purchase
or sales agreement, or any other agreement, in favor of any other creditor or person that may materially affect any of Borrower’s ability
to repay this Loan or Borrower’s ability to perform such obligations under this Loan.
False Statements. Any warranty, representation or statement made or furnished to Lender or to the SBA by Borrower or on
Borrower’s behalf under this Note, the SBA Form 2483, or any other documents furnished to Lender in connection with the loan is
false or misleading in any material respect, either now or at the time made or furnished or becomes false or misleading at any time
thereafter.
Death or Insolvency. The dissolution of Borrower (regardless of whether election to continue is made), any member withdraws
from Borrower, or any other termination of Borrower's existence as a going business or the death of Borrower (or a member, owner or
partner of Borrower), the insolvency of Borrower, the appointment of a receiver for any part of Borrower's property, any assignment
for the benefit of creditors, any type of creditor workout, or the commencement of any proceeding under any bankruptcy or insolvency
laws by or against Borrower and such proceeding is not dismissed within thirty (30) days; or the death of Borrower (or a member,
owner or partner of Borrower).
Creditor or Forfeiture Proceedings. Commencement of foreclosure or forfeiture proceedings, whether by judicial proceeding,
self-help, repossession or any other method, by any creditor of Borrower or by any governmental agency against any collateral securing
the loan. This includes a garnishment of any of Borrower’s accounts, including deposit accounts, with Lender. However, this Event
of Default shall not apply if there is a good faith dispute by Borrower as to the validity or reasonableness of the claim which is the basis
of the creditor proceeding, and if Borrower gives Lender written notice of the creditor proceeding and furnishes reserves or a surety
bond for the creditor proceeding satisfactory to Lender.
Tax Default. Borrower fails to pay any taxes when due.
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 26 of 38
Paycheck Protection Program Note
© 2020 Farleigh Wada Witt. All rights reserved.
April 2020 - 3
Note Signatures. You agree to the terms of this Paycheck Protection Program Note and acknowledge receipt of a completed copy of this
Note. If more than one borrower signs this Note, your obligations are joint and several.
Borrower Name
Eric r Shibley MD PLLC
Borrower Authorized Representative
Eric Shibley
Signature
X
Title
Manager
Date
5/14/2020
FOR CREDIT UNION USE ONLY
Advance funds by
Date
Disbursed by
Adverse Change. A material adverse change occurs in Borrower’s financial condition, or Lender believes the prospect of
payment or performance of this Note is impaired.
Insecurity. Lender, in good faith, deems itself insecure.
10. Lender’s Rights. Upon default, Lender may declare the entire unpaid principal balance under this Note and all accrued unpaid
interest immediately due, and then Borrower will pay that amount. Lender may initiate legal action to obtain judgment to recover the
amount due.
11. Attorneys’ Fees; Expenses. Lender may hire or pay someone else to help collect this Note if Borrower does not pay. Borrower
will pay Lender that amount. This includes, subject to any limits under applicable law, Lender’s attorneys’ fees and Lender’s legal
expenses, whether or not there is a lawsuit, including attorneys’ fees, expenses for bankruptcy proceedings (including efforts to modify
or vacate any automatic stay or injunction), and appeals. If not prohibited by applicable law, Borrower also will pay any court costs, in
addition to all other sums provided by law.
12. Governing Law and Venue. This Note will be governed by federal law applicable to Lender and, to the extent not preempted by
federal law, the laws of the state of Lender’s address set forth above, without regard to its conflicts of law provisions. If there is a
lawsuit, Borrower agrees upon Lender’s request to submit to the jurisdiction of the courts in the county of Lender’s address as set forth
above. Lender and Borrower hereby waive the right to any jury trial in any action, proceeding, or counterclaim brought by either Lender
or Borrower against the other
13. Successor Interests. The terms of this Note shall be binding upon Borrower, and upon Borrower’s heirs, personal
representatives, successors and assigns, and shall inure to the benefit of Lender and its successors and assigns.
14. When Federal Law Applies. When SBA is the holder, this Note will be interpreted and enforced under federal law, including SBA
regulations. Lender or SBA may use state or local procedures for filing papers, recording documents, giving notice, foreclosing liens,
and other purposes. By using such procedures, SBA does not waive any federal immunity from state or local control, penalty, tax, or
liability. As to this Note, Borrower may not claim or assert against SBA any local or state law to deny any obligation, defeat any claim
of SBA, or preempt federal law.
15. General Provisions. Time is of the essence under this Note and in the performance of every term, covenant, and obligation
contained herein. If any part of this Note cannot be enforced, this fact will not affect the rest of the Note. Lender may delay or forgo
enforcing any of its rights or remedies under this Note without losing them. Each Borrower understands and agrees that, with or
without notice to Borrower, Lender may with respect to any other Borrower (a) make one or more additional secured or unsecured
loans or otherwise extend additional credit; (b) alter, compromise, renew, extend, accelerate, or otherwise change one or more times
the time for payment or other terms of any indebtedness, including decreases of the rate of interest on the indebtedness; (c) determine
how, when and what application of payments and credits shall be made on any other indebtedness owing by such other Borrower.
Borrower and any other person who signs, this Note, to the extent allowed by law, waive presentment, demand for payment, and notice
of dishonor. Borrower may not use any oral statement of Lender or SBA to contradict or alter the written terms of this Note.
[IDAHO] ORAL AGREEMENT OR ORAL COMMITMENTS TO LOAN MONEY, EXTEND CREDIT, OR TO FOREBEAR FROM
ENFORCING REPAYMENT OF A DEBT ARE NOT ENFORCEABLE UNDER STATE LAW.
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 27 of 38
COMPANY (LLC) CERTIFICATE
The undersigned, constituting the Members/Managing Members of
____________________________________________, a _________________________ limited liability
(Company Legal Name) (State of Corporation)
company with its principal place of business located at
_______________________________________________ (the “Company”) does hereby certify:
(Address of principal place of business)
The following are true, correct and complete resolutions duly approved by the Members/Managing
Members or other governing body of the Company and that said resolutions are unchanged and are now
in full force and effect:
“RESOLVED, That the members/managers/officers of the Company are, and each of them is,
hereby authorized on behalf of the Company to obtain financing from Idaho Central Credit Union
(“ICCU”) including any of its affiliates or subsidiaries, such items of property, in such amounts
and upon such terms and conditions as the members/managers/officers, in their discretion, may
deem necessary or advisable; and
FURTHER RESOLVED, That each of the members/managers/officers of the Company, and each
of the following parties:
______________________________
______________________________
(Print Name & Title)
(Print Name & Title)
______________________________
______________________________
(Print Name & Title)
(Print Name & Title)
are authorized, directed and empowered to execute and deliver to ICCU, on behalf of the
Company, such contracts, leases, powers of attorney and other documents as may be required by
ICCU in connection with such finance or lease of property; and
FURTHER RESOLVED, That any actions taken by any members/managers/officers of the
Company or any party specifically identified in the foregoing resolutions acting on behalf of the
Company before the date of these resolutions that are within the authority conferred by the
foregoing resolutions are ratified and approved in all respects.”
IN WITNESS WHEREOF I have hereunto set my hand this ______ day of ____________, 20____.
(Day) (Month) (Year)
_________________________________
Member/Managing Member/Secretary
_________________________________
Print Name
Eric R Shibley MD PLLC
Washington
4700 36th Ave SW Seattle, WA 98126
Eric Shibley Manager
14th
May
20
Eric Shibley
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 28 of 38
Certificate Of Completion
Envelope Id: E898B3C6FB4D4C0FB30AD461CBAC1D86
Status: Completed
Subject: Please DocuSign: Eric R Shibley MD PLLC
Source Envelope:
Document Pages: 9
Signatures: 3
Envelope Originator:
Certificate Pages: 5
Initials: 10
DiSeanna Kilgore
AutoNav: Enabled
EnvelopeId Stamping: Enabled
Time Zone: (UTC-07:00) Mountain Time (US & Canada)
4400 Central Way
Chubbuck, ID 83202
dkilgore@iccu.com
IP Address: 204.62.132.100
Record Tracking
Status: Original
5/14/2020 12:21:47 PM
Holder: DiSeanna Kilgore
dkilgore@iccu.com
Location: DocuSign
Signer Events
Signature
Timestamp
Eric Shibley
shibleymedical@outlook.com
Allergan - Enterprise
Security Level: Email, Account Authentication
(None), Access Code
Signature Adoption: Pre-selected Style
Using IP Address: 73.109.30.232
Sent: 5/14/2020 12:25:03 PM
Viewed: 5/14/2020 1:00:14 PM
Signed: 5/14/2020 1:01:14 PM
Electronic Record and Signature Disclosure:
Accepted: 5/14/2020 1:00:14 PM
ID: 55c70637-98ef-4809-bd17-c6c6bf02b234
In Person Signer Events
Signature
Timestamp
Editor Delivery Events
Status
Timestamp
Agent Delivery Events
Status
Timestamp
Intermediary Delivery Events
Status
Timestamp
Certified Delivery Events
Status
Timestamp
Carbon Copy Events
Status
Timestamp
Bart Kleng
bkleng@iccu.com
Commercial Loan Officer
ICCU
Security Level: Email, Account Authentication
(None)
Sent: 5/14/2020 12:25:03 PM
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
PPP Funding
pppfunding@iccu.com
Security Level: Email, Account Authentication
(None)
Sent: 5/14/2020 1:01:16 PM
Viewed: 5/14/2020 2:55:38 PM
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Witness Events
Signature
Timestamp
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 29 of 38
Notary Events
Signature
Timestamp
Envelope Summary Events
Status
Timestamps
Envelope Sent
Hashed/Encrypted
5/14/2020 1:01:16 PM
Certified Delivered
Security Checked
5/14/2020 1:01:16 PM
Signing Complete
Security Checked
5/14/2020 1:01:16 PM
Completed
Security Checked
5/14/2020 1:01:16 PM
Payment Events
Status
Timestamps
Electronic Record and Signature Disclosure
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 30 of 38
CONSUMER DISCLOSURE
From time to time, ICCU (we, us or Company) may be required by law to provide to you certain
written notices or disclosures. Described below are the terms and conditions for providing to you
such notices and disclosures electronically through the DocuSign, Inc. (DocuSign) electronic
signing system. Please read the information below carefully and thoroughly, and if you can
access this information electronically to your satisfaction and agree to these terms and
conditions, please confirm your agreement by clicking the ‘I agree’ button at the bottom of this
document.
Getting paper copies
At any time, you may request from us a paper copy of any record provided or made available
electronically to you by us. You will have the ability to download and print documents we send
to you through the DocuSign system during and immediately after signing session and, if you
elect to create a DocuSign signer account, you may access them for a limited period of time
(usually 30 days) after such documents are first sent to you. After such time, if you wish for us to
send you paper copies of any such documents from our office to you, you will be charged a
$0.00 per-page fee. You may request delivery of such paper copies from us by following the
procedure described below.
Withdrawing your consent
If you decide to receive notices and disclosures from us electronically, you may at any time
change your mind and tell us that thereafter you want to receive required notices and disclosures
only in paper format. How you must inform us of your decision to receive future notices and
disclosure in paper format and withdraw your consent to receive notices and disclosures
electronically is described below.
Consequences of changing your mind
If you elect to receive required notices and disclosures only in paper format, it will slow the
speed at which we can complete certain steps in transactions with you and delivering services to
you because we will need first to send the required notices or disclosures to you in paper format,
and then wait until we receive back from you your acknowledgment of your receipt of such
paper notices or disclosures. To indicate to us that you are changing your mind, you must
withdraw your consent using the DocuSign ‘Withdraw Consent’ form on the signing page of a
DocuSign envelope instead of signing it. This will indicate to us that you have withdrawn your
consent to receive required notices and disclosures electronically from us and you will no longer
be able to use the DocuSign system to receive required notices and consents electronically from
us or to sign electronically documents from us.
All notices and disclosures will be sent to you electronically
Unless you tell us otherwise in accordance with the procedures described herein, we will provide
electronically to you through the DocuSign system all required notices, disclosures,
authorizations, acknowledgements, and other documents that are required to be provided or
made available to you during the course of our relationship with you. To reduce the chance of
you inadvertently not receiving any notice or disclosure, we prefer to provide all of the required
notices and disclosures to you by the same method and to the same address that you have given
us. Thus, you can receive all the disclosures and notices electronically or in paper format through
the paper mail delivery system. If you do not agree with this process, please let us know as
described below. Please also see the paragraph immediately above that describes the
consequences of your electing not to receive delivery of the notices and disclosures
Electronic Record and Signature Disclosure created on: 2/10/2011 12:58:29 PM
Parties agreed to: Eric Shibley
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 31 of 38
electronically from us.
How to contact ICCU:
You may contact us to let us know of your changes as to how we may contact you electronically,
to request paper copies of certain information from us, and to withdraw your prior consent to
receive notices and disclosures electronically as follows:
To contact us by email send messages to: esign@iccu.com
To advise ICCU of your new e-mail address
To let us know of a change in your e-mail address where we should send notices and disclosures
electronically to you, you must send an email message to us at esign@iccu.com and in the body
of such request you must state: your previous e-mail address, your new e-mail address. We do
not require any other information from you to change your email address..
In addition, you must notify DocuSign, Inc. to arrange for your new email address to be reflected
in your DocuSign account by following the process for changing e-mail in the DocuSign system.
To request paper copies from ICCU
To request delivery from us of paper copies of the notices and disclosures previously provided
by us to you electronically, you must send us an e-mail to esign@iccu.com and in the body of
such request you must state your e-mail address, full name, US Postal address, and telephone
number. We will bill you for any fees at that time, if any.
To withdraw your consent with ICCU
To inform us that you no longer want to receive future notices and disclosures in electronic
format you may:
i. decline to sign a document from within your DocuSign session, and on the subsequent
page, select the check-box indicating you wish to withdraw your consent, or you may;
ii. send us an e-mail to esign@iccu.com and in the body of such request you must state
your e-mail, full name, US Postal Address, and telephone number. We do not need any
other information from you to withdraw consent.. The consequences of your withdrawing
consent for online documents will be that transactions may take a longer time to process..
Required hardware and software
Operating Systems:
Windows® 2000, Windows® XP, Windows
Vista®; Mac OS® X
Browsers:
Final release versions of Internet Explorer® 6.0
or above (Windows only); Mozilla Firefox 2.0
or above (Windows and Mac); Safari™ 3.0 or
above (Mac only)
PDF Reader:
Acrobat® or similar software may be required
to view and print PDF files
Screen Resolution:
800 x 600 minimum
Enabled Security Settings:
Allow per session cookies
** These minimum requirements are subject to change. If these requirements change, you will be
asked to re-accept the disclosure. Pre-release (e.g. beta) versions of operating systems and
browsers are not supported.
Acknowledging your access and consent to receive materials electronically
To confirm to us that you can access this information electronically, which will be similar to
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 32 of 38
other electronic notices and disclosures that we will provide to you, please verify that you were
able to read this electronic disclosure and that you also were able to print on paper or
electronically save this page for your future reference and access or that you were able to e-mail
this disclosure and consent to an address where you will be able to print on paper or save it for
your future reference and access. Further, if you consent to receiving notices and disclosures
exclusively in electronic format on the terms and conditions described above, please let us know
by clicking the ‘I agree’ button below.
By checking the ‘I agree’ box, I confirm that:
•
I can access and read this Electronic CONSENT TO ELECTRONIC RECEIPT OF
ELECTRONIC CONSUMER DISCLOSURES document; and
•
I can print on paper the disclosure or save or send the disclosure to a place where I can
print it, for future reference and access; and
•
Until or unless I notify ICCU as described above, I consent to receive from exclusively
through electronic means all notices, disclosures, authorizations, acknowledgements, and
other documents that are required to be provided or made available to me by ICCU during
the course of my relationship with you.
Case 2:20-cr-00174-JCC Document 137-6 Filed 11/26/21 Page 33 of 38
DOJ-01-0000001760
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DOJ-01-0000001761
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DOJ-01-0000001800
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DOJ-01-0000001828
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