Exhibit - Kyc Company Litigation (2025-01-07)

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William Kolbert - United States SBA Declaration of Identity Theft

From: edllp@aol.com (edllp@aol.com)
To: pppidtheftinquiries@sba.gov
Date: Monday, September 30, 2024 at 03:28 PM EDT

Dear Sir or Madam,

Attached per your instructions is my prepared Declaration of Identity Theft, due to an unauthorized
PPP loan that was provided to an unknown perpetrator by a Florida bank using my name and social
security number. Currently, the SBA is now reducing my monthly Social Security Benefits by $476.57
which | depend on for my living expenses. If you have any questions, my business contact
information is below. My mobile number is: a

Thanking you in advance for your immediate help and resolution of this very serious matter.

William I. Kolbert, CPA

Ernest D. Loewenwarter & Co. LLP
200 Old Country Road, Suite 274
Mineola, New York 11501

Phone (516) 739.9777

Fax (516) 739.7388

This message and any attachment are confidential and may be privileged or otherwise protected from disclosure. If you are not the intended recipient, please
notify the sender immediately and delete this message and any attachment from your system. Do not copy them or disclose the contents to any other person. We

process information about our email correspondents and others as explained in our Privacy Notice.

WILLIAM KOLBERT SBA DECLARATION OF ID THEFT 093024.pdf

|p 357.7kB

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United States Small Business Administration
Declaration of Identity Theft

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

Providing the information on this form is voluntary. However, if you do not provide the
information, it may be more difficult to assist you in resolving your identity theft issue. For
Identity Theft Declarations pertaining to direct SBA physical and economic injury disaster
loans, such as COVID Economic Injury Disaster Loans (EIDL), send the completed form
via email to: IDTheftRecords@sba.gov. For Identity Theft Declarations pertaining to
Paycheck Protection Program (PPP) loans, send the completed form via email to:
PPPidtheftinquiries@sba. gov.

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

lv I am submitting this Declaration for myself as a sole proprietor/individual or as the
authorized representative for a business named :
[ I am submitting this Declaration on behalf of my minor child (or I am the guardian of th

[| The identity theft victim is deceased, and I am submitting this Declaration as the
surviving spouse, Court-Appointed Personal Representative, Executor, or Administrator.*
The identity theft victim is incapacitated, and I am submitting this Declaration as the
Power of Attorney, Court-Appointed Guardian, or Conservator.*

Section B — Representative, Conservator, Parent or Guardian contact information*®

Representative’s Last Name: First Name:
Current Street Mailing Address:

City: State: ZIP Code:

Telephone Number: Alternate Telephone Number:

Email address:

Section C — Name and contact information of Identity Theft Victim

Victim’s Last Name: KOLBERT First Name: WILLIAM
Social Security Number (Please provide 9-digit Social Security Number): iii |
Current Street Mailing Address: 4 DONALD DRIVE

City: SYOSSET State: NEW YORK Zip Code:
Telephone Number: 516- Alternate Telephone Number: 51 —

Email address: EDLLP@AOL.COM

SBA Form 3513 (08-21)
Case 1:25-cv-00117-FB-CHK Document1-5 Filed 01/07/25 Page 4 of 9 PagelD #: 76

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

Section D — Declaration

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

[, WILLIAM KOLBERT _ residing at 4 DONALD DRIVE, SYOSSET, NY 11791

hereby declare under penalty of perjury as follows:

Please check and complete as appropriate:

vY On or aboutMAY 2021 _, I allege that someone used my personal identifying information
(PID) or the identifying information of my business without my permission or knowledge
to obtain a loan(s) in my name from the U.S. Small Business Administration or from a
PPP Lender. Please include any known information about the loan (the loan or

application number(s), amount(s) or any other details).
LENDING BANK: BENWORTH CAPITAL

LOAN NUMBER: BR 005

LOAN AMOUNT: $18,803

vY State how you became aware that your identity was used to obtain this/these loan(s):
| BECAME AWARE ON SEPTEMBER 18, 2024 WHEN MY SOCIAL SECURITY BENEFIT DEPOSIT WAS REDUCED BY $476.57.

| THEN CONTACTED SOCIAL SECURITY AS WAS ADVISED THAT THE AMOUNT WAS AN OFFSET CHARGED BY THE SBA. | LATER LEARNED THAT

THE LOAN WAS GIVEN BY A BANK IN FLORIDA NAMED BENWORTH CAPITAL IN MAY 2021. ! NEVER BORROWED A PPP LOAN FROM THIS BANK

NOR HAVE | EVER RECEIVED ANY FUNDS REGARDING THIS LOAN NOR DO | KNOW WHO PERPETRATED THIS FRAUDULENT LOAN.

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

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

Y Are you aware of any other uses of your identity to borrow any other money, including

obtaining credit cards, or to file state or federal income tax returns, if so please describe:
NOT CURRENTLY, NO.

SBA Form 3513 (08-21)
Case 1:25-cv-00117-FB-CHK Documenti1-5 Filed 01/07/25 Page 5of9PagelD #: 77

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

vY You are required to attach and send with this form a copy of a valid driver license,
U.S. Passport, U.S. Military ID, or other valid ID issued by a state or federal agency.

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

9/30/2024 iA _ As ;

Date Signature of Declarant

PRIVACY ACT (5 U.S.C, § 552a)

The information provided in this form is protected by the Privacy Act, 5 U.S.C 552a, which prohibits the
federal government from disclosing personal information about an individual without the individual’s
consent. The Privacy Act authorizes SBA to make certain routine uses of information protected by the
Act as set forth in its System of Records Notices, 69 F.R. 58598. This form or the information provided in
this form may be made available to federal, state, and/or local law enforcement agencies charged with
responsibility for or otherwise involved in investigation, prosecution, enforcement or prevention of such
violations of law.

Under the provisions of the Privacy Act, you are not required to provide social security numbers.
However, if you do not provide the information, it may be more difficult to assist you in resolvingyour
identity theft issue. Note: Any person concerned with the collection, use and disclosure of information,
under the Privacy Act may contact the Chief, FOI/ PA Office, 409 3rd Street, SW, Suite 5900,
Washington, DC 20416 or by e-mail at foia@sba.gov for information about the Agency's procedures
relating to the Privacy Act and the Freedom of Information Act.

PLEASE NOTE: According to the Paperwork Reduction Act, you are not required to respond to this
collection of information unless it displays a currently valid OMB Control Number. The estimated burden
for completing this form, including time for reviewing instructions, gathering data needed, and
completing and reviewing the form is 15 minutes. Comments or questions on the burden estimates should
be sent to U.S. Small Business Administration, Director, Records Management Division, 409 3rd St., SW,
Washington DC 20416, and/or SBA Desk Officer, Office of Management and Budget, New Executive
Office Building, Rm. 10202, Washington DC 20503. PLEASE DO NOT SEND THE FORM TO
THESE ADDRESSES.

SBA Form 3513 (08-21)
Case 1:25-cv-00117-FB-CHK Document1-5- Filed 01/07/25 Page 6 of 9 PagelD #: 78

‘Tf you are submitting this form for your business, by checking this box and signing the Declaration, you are indicating that you are

an authorized representative of the business or the legal owner of the business.
2 By checking this box and signing the Declaration you are indicating that you are an authorized representative (as a parent, guardian,
or te 1 alt. ~

gal guardian) to submit and sign on the minor’s

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

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

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

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

U.S.C. 645, 18 U.S.C. 1001, 18 U.S.C. 1014, 18 U.S.C. 1040, 18 U.S.C. 3571, and any other applicable laws; 2) treble damages and
civil penalties under the False Claims Act, 31 U.S.C. 3729; 3) double damages and civil penalties under the Program Fraud Civil
Remedies Act, 31 U.S.C. 3802; and 4) suspension and/or debarment from all Federal procurement and non-procurement transactions.
Statutory fines may increase if amended by the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015.

Court-Appointed

administrative sanctions

SBA Form 3513 (08-21)
aw »Gase 1:25-cv-00117-FB-CHK Document LiFe? QRH Page 7 of 9 PagelD #: 79

FTC Report Number:

identity Theft Report eRe

1am a victim of Identity theft. This is my official statement about the crime.

Contact Information

First Name: Last Name:
William Kolbert
Address: Phone: Email:

4 Donald Dr “6 edilp@aol.com

Syosset , NY 11791
USA

Personaj Statement

On or about September 20, 2024, | became aware that $476.57 was deducted from my Septem ber 2024 monthly Social Security benefit
payment deposit. | Contacted Social Security soon after that and was advised that the amount that reduced my benefit deposit was an
offset order from the Small Business Administration (SBA). Any notices from SBA were addressed to a Howard Beach, NY address which
was an address I have not lived in since the middle 1980's.. Being extremely upset, it took me several days to finally figure find ontine all of
the pertinent information about this fraudulent loan. My name was not only used to criminally obtain a $18,803 PPP loan, my name was
used as the name of a wholly owned LLC and that a bank located in Florida, Benworth Capital, approved and made this loan under the
Paycheck Protection Program (PPP). | ask that this be resolved ASAP so as to prevent any further reduction or offsets to my future monthly

Social Security benefit payments.

Accounts Affected by the Crime
Fraudulent Personal or Business Loan
Company or Organization: Benworth Capital
Account Number: sos
Date fraud began: Date that | discovered It: Total fraudulent amount:
5/2021 9/2024 $ 18803

Under penalty of perjury, | declare this information is true and correct to the best of my knowledge.

| understand that knowingly making any false statements to the government may violate federal, state, or local criminal statutes, and may result
in a fine, imprisonment, or both.

William Kolbert 9/30/2024
William Kolbert Date

Use this form to prove to businesses and credit bureaus that you have submitted an FTC Identity Theft Report to law enforcement. Some
businesses might request that you also file a report with your local police.

hitps://www.identitytheft.gov/dashboard


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