Exhibit - United States v. Shibley companion docket PPP fraud case (2021-11-26)

Summary

Document 137-7 in United States v. Shibley, Case 2:20-cr-00174-JCC, in the U.S. District Court for the Western District of Washington, filed 11/26/21 and 79 pages long. It opens with Government Exhibit No. 20, marked admitted, a Paycheck Protection Program Borrower Application Form, SBA Form 2483 (04/20), for an LLC listing Eric R Shibley as manager with 100 percent ownership. The form contains the eligibility questions, the applicant's initialed certifications and the statements required by law, and is signed by Eric R Shibley and dated 04/20/2020. The filing closes with lender application pages marked CONFIDENTIAL, including a payroll verification page asking for documentation supporting the Average Monthly Payroll figure.

Summary drafted by a model from the document's text below and checked by script against that text before publication. It is a navigation aid, not a reading of what the document proves. Where AI is used

Full text

Case 2:20-cr-00174-JCC

Document 137-7

Filed 11/26/21

Page 1 of 79

Paycheck Protection Program

OMB Control No.: 3245-0407
Expiration Date: 09/30/2020

Borrower Application Form
Check One:

■ LLC
‰ Sole proprietor ‰ Partnership
‰ C-Corp ‰ S-Corp ‰
‰
(‰
‰ 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

SS1 LLC
Business Address

Business TIN (EIN, SSN)

7509
Primary Contact

Email Address

Eric Shibley

ers98126@gmail.com

4700 36th Ave SW

Average Monthly Payroll:

$

x 2.5 + EIDL, Net of

328000 Advance (if Applicable)
Equals Loan Request:

$

Business Phone

( )
2069384291

820000

Number of Employees: 41

Purpose of the loan
(select more than one):

employee
benefits
■ Payroll տLease / Mortgage Interest տ
■ Utilities 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

Eric R Shibley

Title

Ownership %

100

Manager

TIN (EIN, SSN)

Address

-526 4700 36th Ave SW Seattle W

If questions (1) or (2) below are answered “Yes,” the loan will not be approved.
Question

Yes

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.

No

 
■
‫܆܆‬
■
‫܆܆‬

■
‫܆܆‬

■
‫܆܆‬

If questions (5) or (6) are answered “Yes,” the loan will not be approved.
Question
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 ers

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 ers

‫܆‬

‫܆‬
■

‫■ ܆‬
‫܆‬

‫܆‬

U.S. v. Shibley
‫܆‬
CR20-174 JCC
Government Exhibit No. 20
Admitted ________________

‫܆‬

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?

1

No

‫܆‬

7.

SBA Form 2483 (04/20)

Yes

■

■


Case 2:20-cr-00174-JCC

Document 137-7

Filed 11/26/21

Page 2 of 79

Paycheck Protection Program
Borrower Application Form
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:

ers
_____

ers

_____

ers

_____

ers

_____

ers

_____

ers

_____

ers

_____

ers

_____

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.

Eric Ryan Shibley Digitally signed by Eric Ryan Shibley

04/20/2020

Date: 2020.04.15 19:08:46 -07'00'
_________________________________________________________
Signature of Authorized Representative of Applicant

________________________
Date

Eric R Shibley

04/20/2020

Print Name

Title
2

SBA Form 2483 (04/20)


Case 2:20-cr-00174-JCC

Document 137-7

Filed 11/26/21

Page 3 of 79

Paycheck Protection Program
Borrower Application Form
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
3
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Paycheck Protection Program
Borrower Application Form
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.

4
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DOJ-01-0000001764


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DOJ-01-0000001765


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DOJ-01-0000001807


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DOJ-01-0000001808


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DOJ-01-0000001799


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Paycheck Protection Program

OMB Control No.: 3245-0407
Expiration Date: 09/30/2020

Borrower Application Form
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

SFC LLC
Business Address

Business TIN (EIN, SSN)

Primary Contact
Eric Shibley

Average Monthly Payroll:

Purpose of the loan
(select more than one):

$

37,600

x 2.5 + EIDL, Net of
Advance (if Applicable)
Equals Loan Request:

$

94,000

Business Phone

(
206)
938-4291

3580

4700 36th Ave SW Seattle WA 98126

Email Address
shibley98271@gmail.com

Number of Employees:

6

☐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
Eric R Shibley

Title

Ownership %

Manager

100

TIN (EIN, SSN)
5264

Address
4700 36th Ave SW Seattle WA 98126

If questions (1) or (2) below are answered “Yes,” the loan will not be approved.
Question

Yes

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.

No

 
☐☐
☐☐
☐☐
☐☐

If questions (5) or (6) are answered “Yes,” the loan will not be approved.
Question
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 →

6.

No

☐

☐

ers

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 →

Yes

☐ ☐

ers

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?

☐

☐

1
SBA Form 2483 (04/20)

U.S. v. Shibley
CR20-174 JCC
Government Exhibit No. 21
Admitted ________________

DOJ-01-0000001883


Case 2:20-cr-00174-JCC

Document 137-7

Filed 11/26/21

Page 13 of 79

Paycheck Protection Program
Borrower Application Form
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:
red

_____

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.

ers

_____

Current economic uncertainty makes this loan request necessary to support the ongoing operations of the Applicant.

ers

_____

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.

ers

_____

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.

ers

_____

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.

ers

_____

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.

ers

_____

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.

ers

_____

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.
04/25/2020

_________________________________________________________
Signature of Authorized Representative of Applicant

________________________
Date

Eric R Shibley

Manager

Print Name

Title
2

SBA Form 2483 (04/20)

DOJ-01-0000001884


Case 2:20-cr-00174-JCC

Document 137-7

Filed 11/26/21

Page 14 of 79

Paycheck Protection Program
Borrower Application Form
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”:

 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.
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
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Paycheck Protection Program
Borrower Application Form
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.

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DOJ-01-0000001762


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DOJ-01-0000001763


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DOJ-01-0000001882


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U.S. v. Shibley
CR20-174 JCC
Government Exhibit No. 22
Admitted ________________

DOJ-01-0000004456


ÿ

Case 2:20-cr-00174-JCC

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DOJ-01-0000004457


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Case 2:20-cr-00174-JCC

Document 137-7

Filed 11/26/21

Page 22 of 79

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DOJ-01-0000004458


ÿ

Case 2:20-cr-00174-JCC

Document 137-7

Filed 11/26/21

Page 23 of 79

01234536ÿ089539ÿ08981ÿ
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DOJ-01-0000004459


Case 2:20-cr-00174-JCC

Document 137-7

Filed 11/26/21

Page 24 of 79

DOJ-01-0000004451


Case 2:20-cr-00174-JCC

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Page 25 of 79

DOJ-01-0000004452


Case 2:20-cr-00174-JCC

Document 137-7

Filed 11/26/21

Page 26 of 79

DOJ-01-0000004468


Case 2:20-cr-00174-JCC

Document 137-7

Filed 11/26/21

Page 27 of 79

DOJ-01-0000004469


Case 2:20-cr-00174-JCC

Document 137-7

Filed 11/26/21

Page 28 of 79

DOJ-01-0000004475


Case 2:20-cr-00174-JCC

Document 137-7

Filed 11/26/21

Page 29 of 79

DOJ-01-0000004467


Case 2:20-cr-00174-JCC

Document 137-7

Filed 11/26/21

Page 30 of 79

DOJ-02-0000008853


Case 2:20-cr-00174-JCC

Document 137-7

Filed 11/26/21

Page 31 of 79

DOJ-02-0000008854


Case 2:20-cr-00174-JCC

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U.S. v. Shibley
CR20-174 JCC
Government Exhibit No. 23
Admitted ________________

DOJ-01-0000004391


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Case 2:20-cr-00174-JCC

Document 137-7

Filed 11/26/21

Page 33 of 79

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DOJ-01-0000004392


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Case 2:20-cr-00174-JCC

Document 137-7

Filed 11/26/21

Page 34 of 79

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DOJ-01-0000004393


ÿ

Case 2:20-cr-00174-JCC

Document 137-7

Filed 11/26/21

Page 35 of 79

01234536ÿ089539ÿ08981ÿ
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+331''13ÿ(ÿ(71ÿ&1+1'(ÿÿ55%,1ÿ+&3ÿH1ÿ%31&(%5%13ÿ+'ÿ+ÿ113ÿ5ÿK&5+(%&ÿ12)1'(0ÿ
N33O1 91ÿC1=52ÿ1<ÿP514ÿ3ÿ?Q@ÿABCBDBÿR@Qÿ5ÿS5TBFÿGÿU71ÿV,,)*+(%&+.ÿ+51(/ÿ+&3ÿW1+.(7ÿ3%&%'(+(%&ÿ!VW$ÿ,+&ÿ12)%1ÿ
H)'%&1''1'ÿ(ÿ3%5/ÿ5+,%.%(%1'ÿ+&3ÿ*,13)1'ÿ(ÿ*(1,(ÿ1*./11'0ÿ)'%&1''1'ÿ(7+(ÿ3ÿ&(ÿ,*./ÿ+/ÿH1ÿ5%&13;ÿ5,13ÿ(ÿ,1+'1ÿ*1+(%&';ÿ
ÿ*141&(13ÿ5ÿ'(+(%&-ÿ*1+(%&'0ÿ%-&%&-ÿ(7%'ÿ5ÿ%'ÿ,1(%5%,+(%&ÿ(7+(ÿ(71ÿ+**.%,+&(;ÿ(ÿ(71ÿH1'(ÿ5ÿ%('ÿL&6.13-1;ÿ%'ÿ%&ÿ,*.%+&,1ÿ6%(7ÿ
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*+,(%,1;ÿ%&,.)3%&-ÿ1*./1&(ÿ*+,(%,1'ÿ+&3ÿ'14%,1'ÿ(ÿ(71ÿ*)H.%,ÿ&ÿ(71ÿH+'%'ÿ5ÿ,+(1-%1'ÿ,%(13ÿ%&ÿ]ÿ^00_0;ÿM+('ÿ]];ÿ]];ÿ+&3ÿ]]`ÿ5ÿ
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,.;ÿ1.%-%&;ÿ&+(%&+.ÿ%-%&;ÿ'1J;ÿ+%(+.ÿ'(+()'ÿÿ+-1ÿ!*4%313ÿ(71ÿ+**.%,+&(ÿ7+'ÿ(71ÿ,+*+,%(/ÿ(ÿ1&(1ÿ%&(ÿ+ÿH%&3%&-ÿ,&(+,($eÿH1,+)'1ÿ+..ÿ
ÿ*+(ÿ5ÿ(71ÿ+**.%,+&(8'ÿ%&,1ÿ31%41'ÿ5ÿ+&/ÿ*)H.%,ÿ+''%'(+&,1ÿ*-+eÿÿH1,+)'1ÿ(71ÿ+**.%,+&(ÿ7+'ÿ%&ÿ-3ÿ5+%(7ÿ1J1,%'13ÿ+&/ÿ%-7(ÿ
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(7+(ÿ&1%(71ÿ(71ÿ**.%,+&(ÿÿ+&/ÿ6&1ÿ5ÿ(71ÿ**.%,+&(ÿ7+41ÿ6%(7%&ÿ(71ÿ*+'(ÿ(711ÿ/1+'ÿH11&mÿ!+$ÿ31H+13;ÿ')'*1&313;ÿ31,.+13ÿ%&1.%-%H.1ÿÿÿ
4.)&(+%./ÿ1J,.)313ÿ5ÿ*+(%,%*+(%&ÿ%&ÿ+ÿ(+&'+,(%&ÿH/ÿ+&/ÿ131+.ÿ-1&,/eÿ!H$ÿ5+../ÿ**'13ÿ5ÿ31H+1&(;ÿ6%(7ÿ+ÿ5%&+.ÿ
31(1%&+(%&ÿ'(%..ÿ*1&3%&-eÿ!,$ÿ%&3%,(13;ÿ,&4%,(13;ÿÿ7+3ÿ+ÿ,%4%.ÿI)3-1&(ÿ1&3113ÿ+-+%&'(ÿ/)ÿ5ÿ+&/ÿ5ÿ(71ÿ551&'1'ÿ.%'(13ÿ%&ÿ(71ÿ
1-).+(%&'ÿÿ!3$ÿ31.%&2)1&(ÿ&ÿ+&/ÿ+)&('ÿ613ÿ(ÿ(71ÿn00ÿ:41&1&(ÿÿ%('ÿ%&'()1&(+.%(%1'ÿ+'ÿ5ÿ(71ÿ3+(1ÿ5ÿ1J1,)(%&ÿ5ÿ(7%'ÿ
,1(%5%,+(%&0ÿ
ÿ

ÿÿÿ!"#"$ÿ

ÿ
DOJ-01-0000004394


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DOJ-01-0000004411

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DOJ-02-0000008851


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DOJ-02-0000008852


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Paycheck Protection Program

OMB Control No.: 3245-0407
Expiration Date: 09/30/2020

Borrower Application Form
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

Average Monthly Payroll:

$

x 2.5 + EIDL, Net of
Advance (if Applicable)
Equals Loan Request:

$

)

Email Address

Number of Employees:

Purpose of the loan
(select more than one):

Payroll

Lease / Mortgage Interest

Utilities

Other (explain):__________________

Applicant Ownership
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

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.

Yes

Question
5.

No

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

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?

SBA Form 2483 (04/20)

U.S. v. Shibley
CR20-174 JCC
Government Exhibit No. 24
Admitted ________________

DOJ-02-0000009192

No


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Paycheck Protection Program
Borrower Application Form
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 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
2

SBA Form 2483 (04/20)

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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”:
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.
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
3
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Paycheck Protection Program
Borrower Application Form
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.

4
SBA Form 2483 (04/20)

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Required Supporting Documentation*

Qualified PPP Payroll Expenses
Aggregate Annual Payroll Costs in 2019
(a)
(b)
(c)
(d)
(e)

(f)
(g)

Less:
Compensation paid to employees in excess of $100,000
(h)
(i)
(j)
(k)

Total annual compensation of employees whose principal place of residence is
outside of the United States
Total Annual Exclusions (k+l):

(l)
(m)

Annual Allowable Payroll Costs (g-m):
Divide by 12 (n/12):

Average Monthly Payroll (should match page 1 of application)

(n)

(o)

Note: Summary documentation in support of the above items should be uploaded in support of borrower's identified qualified expenses.
Additional Questions

DOJ-02-0000009196


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Attachments
Application
List 100% of equity ownership of the applicant, if
applicable
Addendum A (Question #3 from Page 1 of the
Application, if applicable)
Addendum B (Question #4 from Page 1 of the
Application, if applicable)
Required Supporting Documentation
(choose one of
the following)

Form 941 for 2019: Employer’s QUARTERLY Federal Tax
Return, for all four quarters of 2019
or
Form 944 for 2019: Employer's ANNUAL Federal Tax
Return,
or
For Sole Proprietors or Independent Contractors, one
or more of the following:
2019 Complete 1040 Tax Returns, if filed (2018
Complete 1040 Tax Returns if 2019 not yet filed
Income & Expense Statement
Form 1099-MISC
Summary of the Borrower’s payroll registry on or
around February 15th, 2020 (REQUIRED)
Summary Documentation in support of other payroll costs, including, but not limited to (if applicable):
Benefits (i.e., payment for vacation, parental, family,
medical or sick leave)
Allowance for separation or dismissal
Payment for the provision of employee benefits
consisting for group health care coverage, including
insurance premiums, and retirement
Payment of state and local taxes assessed on
compensation of employees
Additional Documentation as Needed
Other
Other

DOJ-02-0000009197


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DOJ-02-0000009218


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DOJ-02-0000009219


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DOJ-02-0000009217


DocuSign Envelope ID: 01C93432-BFA2-4B53-B627-92AB325E9F13

Case 2:20-cr-00174-JCC

Document 137-7

THIS IS A COPY

Filed
11/26/21 Copy
Page
of 79
The Authoritative
of this52
record
is held at www.docusign.net

Paycheck Protection Program

OMB Control No.: 3245-0407
Expiration Date: 09/30/2020

Borrower Application Form
Check One:

 Sole proprietor  Partnership
C-Corp  S-Corp 
X 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

ES1 LLC
Business Address

Business TIN (EIN, SSN)

Business
4700 36th Ave SW
Address label
Business
Address
Line2 label

Business Tin label

Seattle

WA

Average Monthly Payroll:

$ 40000

Business Phone

(

5849

)
(206)938-4291

Primary Contact

98126

Primary Contact label

x 2.5 + EIDL, Net of
Advance (if Applicable)
Equals Loan Request:

$

ERIC R SHIBLEY

100000

Email Address
Email label
ers98126@gmail.com

Number of Employees: 5

Purpose of the loan

benefits
☐
:__________________
XLease / Mortgage Interest ☐
X Payroll ☐
XUtilities ☐
XOther (explain) employee

(select more than one):

W
IE

Applicant Ownership
List all owners of 20% or more of the equity of the Applicant. Attach a separate sheet if necessary.
Owner Name
Owner 1

Title

Ownership %

Manager

ERIC R SHIBLEY

100

TIN (EIN, SSN)

-5264

V
Y

If questions (1) or (2) below are answered “Yes,” the loan will not be approved.
Question

Address

4700 36th Ave SW

Yes

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.

P
O

C

No

  Questio
X
☐☐
n 1 No
Questio

☐☐
X
n 2 No
☐
X ☐
X
☐☐

If questions (5) or (6) are answered “Yes,” the loan will not be approved.

5.

Question

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?

Yes

No

☐

Questio
X
☐
n 5 No

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)?

Questio
X
☐ ☐
n 6 No

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?

☐
X 

☐

8.

Is the Applicant a franchise that is listed in the SBA’s Franchise Directory?

☐

☐
X 

CONFIDENTIAL
SBA Form 2483 (04/20)

1

U.S. v. Shibley
CR20-174 JCC
WF000017
Government Exhibit No. 25
Admitted ________________


DocuSign Envelope ID: 01C93432-BFA2-4B53-B627-92AB325E9F13

Case 2:20-cr-00174-JCC

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Paycheck Protection Program
Borrower Application Form
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.

W
IE

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:

V
Y

_____

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.

P
O

C

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.
04/15/2020 | 5:48:53 PM CDT
_________________________________________________________
________________________
Signature of Authorized Representative of Applicant
Date

_____

ERIC R SHIBLEY

04/15/2020

Print Name

Title

CONFIDENTIAL
SBA Form 2483 (04/20)

2

WF000018


DocuSign Envelope ID: 01C93432-BFA2-4B53-B627-92AB325E9F13

Case 2:20-cr-00174-JCC

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Paycheck Protection Program
Borrower Application Form
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.

W
IE

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;

V
Y

 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).

P
O

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).

C

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

CONFIDENTIAL
SBA Form 2483 (04/20)

3

WF000019


DocuSign Envelope ID: 01C93432-BFA2-4B53-B627-92AB325E9F13

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Paycheck Protection Program
Borrower Application Form
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.

W
IE

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.

V
Y

P
O

C

CONFIDENTIAL
SBA Form 2483 (04/20)

4

WF000020


DocuSign Envelope ID: 01C93432-BFA2-4B53-B627-92AB325E9F13

Case 2:20-cr-00174-JCC

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Addendum A – Affiliate Information
Please complete this form if you answered YES to question 3, if you replied NO please continue to the next page.
Question 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.
Affiliate 1
Business Name

Eric R Shibley MD PLLC
Business Industry

Tax ID

Healthcare

9052

Sales of the Affiliate Business

Number Employees of the Affiliate Business

180000

5

NAICS Code

Size Standard ($)

621111

180000

W
IE

Affiliate 2
Business Name

The A team Holdings LLC
Business Industry

Tax ID

V
Y
7088

Real Estate Development
Sales of the Affiliate Business

Number Employees of the Affiliate Business

4850000

48

NAICS Code

Size Standard ($)

P
O

236115

Affiliate 3
Business Name

Seattle's Finest Cannabis

C

Business Industry

Packaging

Sales of the Affiliate Business

120000

4850000

Tax ID

3580
Number Employees of the Affiliate Business

5

NAICS Code

Size Standard ($)

561910

1200005

Affiliate 4
Business Name

Business Industry

Tax ID

Sales of the Affiliate Business

Number Employees of the Affiliate Business

NAICS Code

Size Standard ($)

CONFIDENTIAL

WF000021


DocuSign Envelope ID: 01C93432-BFA2-4B53-B627-92AB325E9F13

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Affiliate 5
Business Name

Business Industry

Tax ID

Sales of the Affiliate Business

Number Employees of the Affiliate Business

NAICS Code

Size Standard ($)

Affiliate 6
Business Name

Business Industry

Tax ID

Sales of the Affiliate Business

Number Employees of the Affiliate Business

NAICS Code

Size Standard ($)

V
Y

Affiliate 7
Business Name

Business Industry

Tax ID

P
O

Sales of the Affiliate Business

NAICS Code

Affiliate 8

C

Business Name

W
IE

Number Employees of the Affiliate Business

Size Standard ($)

Business Industry

Tax ID

Sales of the Affiliate Business

Number Employees of the Affiliate Business

NAICS Code

Size Standard ($)

CONFIDENTIAL

WF000022


DocuSign Envelope ID: 01C93432-BFA2-4B53-B627-92AB325E9F13

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Affiliate 9
Business Name

Business Industry

Tax ID

Sales of the Affiliate Business

Number Employees of the Affiliate Business

NAICS Code

Size Standard ($)

Affiliate 10
Business Name

Business Industry

Tax ID

Sales of the Affiliate Business

Number Employees of the Affiliate Business

NAICS Code

Size Standard ($)

W
IE

V
Y

P
O

C

CONFIDENTIAL

WF000023


DocuSign Envelope ID: 01C93432-BFA2-4B53-B627-92AB325E9F13

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Addendum B – EISL Use of Funds
Please complete this form if you answered YES to question 4, if you replied NO please continue to the next page.
Question 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.
EIDL Loan#

EIDL Loan Date

EIDL Loan Amount

EIDL Use of Funds

W
IE

V
Y

P
O

C

CONFIDENTIAL

WF000024


DocuSign Envelope ID: 01C93432-BFA2-4B53-B627-92AB325E9F13

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Please add additional owners of 20% or more of the equity of the Applicant.
Owner Name

Title

Ownership %

TIN (EIN, SSN)

Address

W
IE

V
Y

P
O

C

CONFIDENTIAL

WF000025


DocuSign Envelope ID: 01C93432-BFA2-4B53-B627-92AB325E9F13

2:20-cr-00174-JCC
PayrollCase
Verification

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Please upload documentation to support the “Average Monthly Payroll” figure submitted on the PPP
application. Documentation may include:
1. Payroll Tax Form 941 (include last 4 quarters), Payroll Tax Form 944, Tax Form 940, or Payroll
Summary Reports from your payroll provider;
2. Form 1099-Misc;
3. Some payroll providers such as ADP; Paychex; Gusto have published specific PPP Reports. Please
provide these if available; or
4. Annual Income and Expense statement (for sole proprietorships only) or Business Tax Return
(Schedule C or Form 1120S or 1065)
Documents in numbers 1, 2, and 3 above are recommended as they may result in reduced processing
times of your loan application.

W
IE

Please limit file size to 5MB total (and 5 documents maximum).

V
Y

P
O

C

CONFIDENTIAL

WF000026


Case 2:20-cr-00174-JCC

CONFIDENTIAL

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WF000013


Case 2:20-cr-00174-JCC

CONFIDENTIAL

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WF000014


DocuSign Envelope ID: 01C93432-BFA2-4B53-B627-92AB325E9F13

Case 2:20-cr-00174-JCC

Document 137-7

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Page
64 ofis 79
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E
I

V
Y

P
O

C

CONFIDENTIAL

WF000031


DocuSign Envelope ID: 01C93432-BFA2-4B53-B627-92AB325E9F13

Case 2:20-cr-00174-JCC

Document 137-7

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65 ofis 79
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W
E
I

V
Y

P
O

C

CONFIDENTIAL

WF000032


DocuSign Envelope ID: 49678393-8F12-47AE-ACAE-7B9DE7A6B49C

Case 2:20-cr-00174-JCC

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Paycheck Protection Program

OMB Control No.: 3245-0407
Expiration Date: 09/30/2020

Borrower Application Form
Check One:

 Sole proprietor  Partnership
C-Corp  S-Corp 
X 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

Shibley Medical

Business Legal Name

Eric R Shibley MD PLLC
Business Address

Business TIN (EIN, SSN)

Business
4700 36th Ave SW
Address label
Business
Address
Line2 label

Business Tin label

Seattle

WA

Average Monthly Payroll:

$ 40000

98126

Business Phone

(

9052

)
(206)938-4291

Primary Contact
Primary Contact label

x 2.5 + EIDL, Net of
Advance (if Applicable)
Equals Loan Request:

$

Email Address
Email label
ers98126@gmail.com

ERIC R SHIBLEY

100000

Number of Employees: 5

Purpose of the loan

benefits
☐
:__________________
XLease / Mortgage Interest ☐
X Payroll ☐
XUtilities ☐
XOther (explain) employee

(select more than one):

W
IE

Applicant Ownership
List all owners of 20% or more of the equity of the Applicant. Attach a separate sheet if necessary.
Owner Name
Owner 1

Title

Ownership %

Manager

ERIC R SHIBLEY

100

TIN (EIN, SSN)

-5264

V
Y

If questions (1) or (2) below are answered “Yes,” the loan will not be approved.
Question

Address

4700 36th Ave SW

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?

  Questio
X
☐☐
n 1 No

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?

☐☐
X
n 2 No

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.

P
O

C

Questio

☐
X ☐
X
☐☐

If questions (5) or (6) are answered “Yes,” the loan will not be approved.
5.

Question

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?

Yes

No

☐

Questio
X
☐
n 5 No

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)?

Questio
X
☐ ☐
n 6 No

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?

☐
X 

☐

8.

Is the Applicant a franchise that is listed in the SBA’s Franchise Directory?

☐

☐
X 

CONFIDENTIAL
SBA Form 2483 (04/20)

U.S. v. Shibley
CR20-174 JCC
1 Government Exhibit No. 26
Admitted ________________

WF000001


DocuSign Envelope ID: 49678393-8F12-47AE-ACAE-7B9DE7A6B49C

Case 2:20-cr-00174-JCC

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Paycheck Protection Program
Borrower Application Form
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.

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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:

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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.

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Current economic uncertainty makes this loan request necessary to support the ongoing operations of the Applicant.

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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.

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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.

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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.

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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.

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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.

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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.
04/15/2020 | 5:34:28 PM CDT
_________________________________________________________
________________________
Signature of Authorized Representative of Applicant
Date

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ERIC R SHIBLEY

04/15/2020

Print Name

Title

CONFIDENTIAL
SBA Form 2483 (04/20)

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Paycheck Protection Program
Borrower Application Form
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.

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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;

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 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).

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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).

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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

CONFIDENTIAL
SBA Form 2483 (04/20)

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Paycheck Protection Program
Borrower Application Form
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.

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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.

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Addendum A – Affiliate Information
Please complete this form if you answered YES to question 3, if you replied NO please continue to the next page.
Question 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.
Affiliate 1
Business Name

The A Team Holdings LLC
Business Industry

Tax ID

Real Estate Development

7088

Sales of the Affiliate Business

Number Employees of the Affiliate Business

4850000

48

NAICS Code

Size Standard ($)

236115

4850000

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Affiliate 2
Business Name

ES1 LLC
Business Industry

Tax ID

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5849

Real Estate
Sales of the Affiliate Business

Number Employees of the Affiliate Business

120000

5

NAICS Code

Size Standard ($)

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531110

Affiliate 3
Business Name

Seattle's Finest Cannabis

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Business Industry

Packaging

Sales of the Affiliate Business

120000

120000

Tax ID

3580
Number Employees of the Affiliate Business

5

NAICS Code

Size Standard ($)

561910

120000

Affiliate 4
Business Name

Business Industry

Tax ID

Sales of the Affiliate Business

Number Employees of the Affiliate Business

NAICS Code

Size Standard ($)

CONFIDENTIAL

WF000005


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Affiliate 5
Business Name

Business Industry

Tax ID

Sales of the Affiliate Business

Number Employees of the Affiliate Business

NAICS Code

Size Standard ($)

Affiliate 6
Business Name

Business Industry

Tax ID

Sales of the Affiliate Business

Number Employees of the Affiliate Business

NAICS Code

Size Standard ($)

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Affiliate 7
Business Name

Business Industry

Tax ID

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Sales of the Affiliate Business

NAICS Code

Affiliate 8

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Business Name

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Number Employees of the Affiliate Business

Size Standard ($)

Business Industry

Tax ID

Sales of the Affiliate Business

Number Employees of the Affiliate Business

NAICS Code

Size Standard ($)

CONFIDENTIAL

WF000006


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Affiliate 9
Business Name

Business Industry

Tax ID

Sales of the Affiliate Business

Number Employees of the Affiliate Business

NAICS Code

Size Standard ($)

Affiliate 10
Business Name

Business Industry

Tax ID

Sales of the Affiliate Business

Number Employees of the Affiliate Business

NAICS Code

Size Standard ($)

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Addendum B – EISL Use of Funds
Please complete this form if you answered YES to question 4, if you replied NO please continue to the next page.
Question 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.
EIDL Loan#

EIDL Loan Date

EIDL Loan Amount

EIDL Use of Funds

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Please add additional owners of 20% or more of the equity of the Applicant.
Owner Name

Title

Ownership %

TIN (EIN, SSN)

Address

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PayrollCase
Verification

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Please upload documentation to support the “Average Monthly Payroll” figure submitted on the PPP
application. Documentation may include:
1. Payroll Tax Form 941 (include last 4 quarters), Payroll Tax Form 944, Tax Form 940, or Payroll
Summary Reports from your payroll provider;
2. Form 1099-Misc;
3. Some payroll providers such as ADP; Paychex; Gusto have published specific PPP Reports. Please
provide these if available; or
4. Annual Income and Expense statement (for sole proprietorships only) or Business Tax Return
(Schedule C or Form 1120S or 1065)
Documents in numbers 1, 2, and 3 above are recommended as they may result in reduced processing
times of your loan application.

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Please limit file size to 5MB total (and 5 documents maximum).

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WF000012

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