Lender's Application: Paycheck Protection Program Loan Guaranty (SBA Form 2484, Revised March 18, 2021)

Summary

Lender's Application for the Paycheck Protection Program Loan Guaranty, SBA Form 2484 (Revised 3/21), OMB Control No. 3245-0407, expiring 9/30/2021, revised March 18, 2021. It is an unfilled form collecting information about the lender, the applicant, the loan guaranty request, sources and uses of funds, loan structure and compliance, and says the rules include the Economic Aid Act and Title V of the American Rescue Plan Act of 2021. The structure fields list a 100% guarantee, a 60 month term with payment deferred, and a 1% interest rate calculated on a non-compounding, non-adjustable basis, with the loan amount based on average monthly payroll multiplied by 2.5. Applicant fields include gross income from 2019 or 2020 for those using SBA Form 2483-C.

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                                                                   Paycheck Protection Program                                                  OMB Control No.: 3245-0407
                                                Lender’s Application - Paycheck Protection Program Loan Guaranty                                  Expiration Date: 9/30/2021
                                                                      Revised March 18, 2021

The purpose of this form is to collect identifying information about the Lender, the Applicant, the loan guaranty request, sources and uses of funds, the
proposed structure (which includes pricing and the loan term), and compliance with SBA Loan Program Requirements. This form reflects the data
fields that will be collected electronically from lenders; no paper version of this form is required or permitted to be submitted. As used in this
application, “Paycheck Protection Program Rules” refers to the rules in effect at the time you submit this application that have been issued by the Small
Business Administration (SBA) and the Department of the Treasury implementing the Paycheck Protection Program under Division A, Title I of the
Coronavirus Aid, Relief, and Economic Security Act (CARES Act), the Economic Aid to Hard-Hit Small Businesses, Nonprofits, and Venues Act, and
Title V of the American Rescue Plan Act of 2021.
Instructions for Lenders
All Paycheck Protection Program (PPP) loans are processed by all Lenders under delegated authority from SBA. This application must be submitted
and signed electronically in accordance with program requirements, and the information requested is to be retained in the Lender’s loan file.
 A. Lender Information
 Lender Name:                                                                                                  Lender Location ID:
 Address:                                                            City:                                     St:                       Zip:
 Lender Contact:                                                  Ph:   (     )    -                     Cell or Ext: (      )       -
 Contact Email:            _______________________________________________                  Title:       _______________________________________________

 B. Applicant Information (All Applicant Ownership information provided by the Applicant on SBA Form 2483 or 2483-C must also be submitted
 electronically)
     Check One:        Sole proprietor  Partnership  C-Corp  S-Corp  LLC  Independent contractor
                       Self-employed individual  501(c)(3) nonprofit  501(c)(6) organization
                       Single member LLC (self-employed individual)  Qualified joint venture (self-employed individual)
                       501(c)(19) veterans organization  Other 501(c) organization  Housing cooperative  Tribal business
                       Other _______________________
      Applicant Legal Name:                                                NAICS Code:

 Applicant
             DBA or Tradename (if applicable):                                         Business Tax ID:
             Year of Establishment (if applicable):                                   Number of Employees:
                                                         No more than 500 employees (or 300 employees, if applicable) unless “per location” exception
             Applicant Size Standard (including         applies
             affiliates, if applicable) (check one):     SBA industry size standards
                                                         SBA alternative size standard
             Applicant Street Address (no P.O.
                                                                                       City, State, Zip:
             Box Addresses allowed):
             Applicant Primary Contact:                                                Phone:        (     )         -

                                                       Total Gross Income (from IRS Form 1040, Schedule C, Line 7)               Tax Year Used for Gross Income
             Complete this line only if Applicant
             submitted SBA Form 2483-C:                                                                                           2019
                                                       $
                                                                                                                                  2020

 C. Loan Structure Information
 Amount of Loan Request:     $                         Guarantee %:    100%     Loan Term in # of Months:      60    Payment:     Deferred
 Applicant must provide documentation to Lender supporting how the loan amount was calculated in accordance with the Paycheck Protection
 Program Rules and Lender must retain all such supporting documentation in Lender’s file.
 Interest Rate: 1% (calculated on a non-compounding, non-adjustable basis)

 D. Loan Amount Information
 Average Monthly Payroll multiplied by 2.5
     If Applicant submitted SBA Form 2483-C, use the amount entered in B in either table, plus the amount
     entered in C for Applicants with employees (if applicable), multiplied by 2.5                                               $


 Refinance of Eligible Economic Injury Disaster Loan (EIDL) (Do Not Include Any EIDL Advance (see
                                                                                                                                 $
 Paycheck Protection Program Rules))
 Total                                                                                                                           $




SBA Form 2484 (Revised 3/21)                                                       1
 E. General Eligibility (If the answer is no to any, the loan cannot be approved)
 • The Applicant has certified to the Lender that (1) it was in operation on February 15, 2020, has not permanently closed,
    and was either an eligible self-employed individual, independent contractor, or sole proprietorship with no employees or
    had employees for whom it paid salaries and payroll taxes or paid independent contractors, as reported on Form(s) 1099-
    MISC; (2) current economic uncertainty makes this loan request necessary to support the ongoing operations of the
    Applicant; (3) the funds will be used to retain workers and maintain payroll, or make payments for mortgage interest, rent,       Yes    No
    utilities, covered operations expenditures, covered property damage costs, covered supplier costs, and covered worker
    protection expenditures; and (4) the Applicant has not and will not receive another loan under the Paycheck Protection
    Program, section 7(a)(36) of the Small Business Act (15 U.S.C. 636(a)(36)) (this does not include Paycheck Protection
    Program second draw loans, section 7(a)(37) of the Small Business Act (15 U.S.C. 636(a)(37)).
 • The Applicant has certified to the Lender that the Applicant, together with its affiliates (if applicable), (1) is an
    independent contractor, self-employed individual, or sole proprietor with no employees; (2) if not a housing cooperative,
    eligible 501(c)(6) organization, other eligible 501(c) organization, or eligible destination marketing organization, employs
    no more than the greater of 500 employees or, if applicable, meets the size standard in number of employees established by
    the SBA in 13 C.F.R. 121.201 for the Applicant’s industry; (3) if a housing cooperative, employs no more than 300
    employees; (4) if an eligible 501(c)(6) organization, other eligible 501(c) organization, or eligible destination marketing
    organization, employs no more than 300 employees per physical location; (5) if NAICS 72 or a 501(c)(3) organization,              Yes    No
    employs no more than 500 employees per physical location; (6) if a news organization that is majority owned or controlled
    by a NAICS code 511110 or 5151 business, a nonprofit public broadcasting entity with a trade or business under NAICS
    code 511110 or 5151, or an Internet-only news or periodical publisher assigned NAICS code 519130 and engaged in the
    collection and distribution of local or regional and national news and information, employs no more than 500 employees
    (or, if applicable, the size standard in number of employees established by SBA in 13 C.F.R. 121.201 for the Applicant’s
    industry) per location; or (7) is a small business under the applicable revenue-based size standard established by SBA in 13
    C.F.R. 121.201 for the Applicant’s industry or under the SBA alternative size standard.
 • The Applicant has certified to the Lender that (1) it has not been approved for a Shuttered Venue Operator (SVO) grant
    from SBA as of the date of the loan application, and acknowledged that if the Applicant is approved for an SVO grant
    before SBA issues a loan number for the loan, the Applicant is ineligible for the loan and acceptance of any loan proceeds
    will be considered an unauthorized use; (2) the President, the Vice President, the head of an Executive department, or a
    Member of Congress, or the spouse of such person as determined under applicable common law, does not directly or                  Yes    No
    indirectly hold a controlling interest in the Applicant, with such terms having the meanings provided in Section 322 of the
    Economic Aid to Hard-Hit Small Businesses, Nonprofits, and Venues Act; and (3) the Applicant is not an issuer, the
    securities of which are listed on an exchange registered as a national securities exchange under section 6 of the Securities
    Exchange Act of 1934 (15 U.S.C. 78f).

 F. Applicant Certification of Eligibility (If not true, the loan cannot be approved)
 • The Applicant has certified to the Lender that the Applicant is eligible under the Paycheck Protection Program Rules.                 True

 G. Franchise/License/Jobber/Membership or Similar Agreement (If a franchise and not listed in the SBA Franchise Directory, the loan
 cannot be approved)
 • The Applicant has represented to the Lender that it is a franchise.                                                                Yes    No
 • The Applicant has represented that the franchise is listed in SBA’s Franchise Directory.                                           Yes    No
 • If Yes, enter the SBA Franchise Identifier Code here: _______________

 H. Character Determination (If no, the loan cannot be approved)
 • The Applicant has represented to the Lender that neither the Applicant (if an individual) nor any individual owning 20% or
   more of the equity of the Applicant is presently incarcerated or, for any felony, presently subject to an indictment, criminal     Yes     No
   information, arraignment, or other means by which formal criminal charges are brought in any jurisdiction.
 • The Applicant has represented to the Lender that neither the Applicant (if an individual) nor any owner of the Applicant has
   within the last 5 years, for any felony involving fraud, bribery, embezzlement, or a false statement in a loan application or      Yes     No
   an application for federal financial assistance: 1) been convicted; 2) pleaded guilty; 3) pleaded nolo contendere; or 4)
   commenced any form of parole or probation (including probation before judgment).

 I. Prior Loss to Government/Delinquent Federal Debt (If no, the loan cannot be approved)
 • The Applicant has certified to the Lender that neither the Applicant nor any owner is presently suspended, debarred,
   proposed for debarment, declared ineligible, voluntarily excluded from participation in this transaction by any Federal           Yes     No
   department or agency, or presently involved in any bankruptcy.
 • The Applicant has certified to the Lender that neither the Applicant nor any of its owners, nor any business owned or
   controlled by any of them, ever obtained a direct or guaranteed loan from SBA or any other Federal agency (other than a           Yes     No
   Federal student loan made or guaranteed through a program administered by the Department of Education) that is (a)
   currently delinquent, or (b) has defaulted in the last 7 years and caused a loss to the government.

 J. U.S. Employees (If no, the loan cannot be approved)
 • The Applicant has certified that the principal place of residence for all employees included in the Applicant’s payroll           Yes     No
    calculation is the United States.



SBA Form 2484 (Revised 3/21)                                                   2
 K. Fees (If yes, Lender may not pass any agent fee through to the Applicant or offset or pay the fee with the proceeds of this loan)
 • Has the Lender directly contracted with a third party to assist in the preparation of the loan application or application      Yes         No
    materials, or to perform other services in connection with this loan?


                    SBA Certification to Financial Institution under Right to Financial Privacy Act (12 U.S.C. 3401)
By signing SBA Form 2483 or 2483-C, Borrower Application Form in connection with this application for an SBA-guaranteed loan, the Applicant
certifies that it has read the Statements Required by Law and Executive Orders, which is attached to SBA Form 2483 or 2483-C. As such, SBA certifies
that it has complied with the applicable provisions of the Right to Financial Privacy Act of 1978 (12 U.S.C. 3401) and, pursuant to that Act, no further
certification is required for subsequent access by SBA to financial records of the Applicant/Borrower during the term of the loan guaranty.

                                                                 Lender Certification
On behalf of the Lender, I certify that:
•     The Lender has complied with the applicable lender obligations set forth in paragraphs C.3.a.-c. of the interim final rule “Paycheck Protection
      Program as Amended by Economic Aid Act” (issued on January 6, 2021), and any amendments thereto.
•     The Lender has obtained and reviewed the required application (including documents demonstrating qualifying payroll amounts) of the Applicant
      and will retain copies of such documents in the Applicant’s loan file.
•     The Lender will register in sam.gov no later than thirty (30) days from the date of the first disbursement of a PPP loan made by the Lender after
      January 7, 2021 and will provide SBA with the Lender’s unique entity identifier.
I certify that:
•     Neither the undersigned Authorized Lender Official, nor such individual’s spouse or children, has a financial interest in the Applicant.

             Authorized Lender Official:                                                                     Date:
                                                                  Signature

                    Type or Print Name:                                                                      Title:


NOTE: According to the Paperwork Reduction Act, you are not required to respond to this collection of information unless it displays a currently valid
OMB Control Number. The estimated burden for completing this form, including time for reviewing instructions, gathering data needed, and completing
and reviewing the form is 25 minutes per response. Comments or questions on the burden estimates should be sent to U.S. Small Business
Administration, Director, Records Management Division, 409 3rd St., SW, Washington DC 20416, and/or SBA Desk Officer, Office of Management and
Budget, New Executive Office Building, Rm. 10202, Washington DC 20503. PLEASE DO NOT SEND FORMS TO THESE ADDRESSES.




SBA Form 2484 (Revised 3/21)                                                  3


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