Exhibit V, Paycheck Protection Program Borrower Application Form — Case 5:24-cr-00292-PCP, Document 44-22
Summary
This is Exhibit V, a Paycheck Protection Program Borrower Application Form (SBA Form 2483 (04/20)) for the business Alternative Health Services Inc, with Cassie Will-darnall shown as the primary contact. The loan calculation lists an Average Monthly Payroll of $387595.67 multiplied by 2.5 and a loan request of $968989.00, with 10 shown as the Number of Employees. The form carries yes or no questions about suspension, debarment, delinquent federal loans, an SBA Economic Injury Disaster Loan received between January 31, 2020 and April 3, 2020, and criminal charges. The form also prints SBA notices on the Freedom of Information Act, civil rights and debarment and suspension.
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
Cite this document
“Exhibit V, Paycheck Protection Program Borrower Application Form — Case 5:24-cr-00292-PCP, Document 44-22.”
Archived at Pandemic Darlings, https://pandemicdarlings.com/source-documents/gov-uscourts-cand-430212-44-22-f09c1d6084/
, SHA-256 64b94be87cbb02bf0f8a1d77307c05e2fc63a4203dc898f81367f07a870b14ee.Full text
Case 5:24-cr-00292-PCP Document 44-22 Filed 04/09/25 Page 1 of 6
EXHIBIT V
DocuSign Envelope ID: 590ABEB6-F87F-41A3-8CEF-764546802B1 D
Case 5:24-cr-00292-PCP Document 44-22 Filed 04/09/25 Page 2 of 6
Paycheck Protection Program 0MB Control No.: 3245-0407
Borrower Application Form Expiration Date: 09/30/2020
Check One: □ Sole proprietor □ Partnership ca::c-Corp □ S-Corp □ LLC DBA or Tradename if Applicable
□ Independent contractor □ Eligible self-employed individual
□ 50l(c)(3) nonprofit D 50 I (c)(19) veterans organization
□ Tribal business (sec. 3l(b)(2)(C) of Small Business Act) □ Other
Business L!~al Name
Alternative Health Services Inc
Business Address Business TIN (EIN, SSN) Business Phone
15559 Union Avenue 125
Los Gatos CA 95032 Primary Contact Email Address
Cassie Will-darnall
Average Monthly Payroll: $ 387595.67 x 2.5 + EIDL, Net of $ 968989.00 Number of Employees: 10
Advance (if Applicable)
Eauals Loan Reauest:
Purpose of the loan
(select more than one): lli!Payroll □ Lease / Mortgage Interest Qfutilities □other (explain):
Applicant Ownership
List all owners of20% or more of the equity ofthe Applicant. Attach a separate sheet if necessary.
Owner Name Title Ownership% TIN (EIN, SSN) Address
Cassie IMll-damall Partner 100.00 111 Belwood Gateway Los Gatos CA 95032
Ifquestions (1) or (2) below are answered "Yes "the loan will not be approved.
Question I Yes I No
I. Is the Applicant or any owner ofthe 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 □ 1::81
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 □ []I
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.
I(questions (5) or (6) are answered "Yes." the loan will not be approved.
Question Yes No
5. Is the Applicant (if an individual) or any individual owning 20% or more ofthe 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 ~ obation 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 I)
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 pro~ n before judgment)?
□
Initial here to confirm your response to question 6 ->
7. Is the United States the principal place ofresidence for all employees of the Applicant included in the I]] □
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)
US-0000307
US-0000307
DocuSign Envelope ID: 590ABEB6-F87F-41A3-8CEF-764546802B1 D
Case 5:24-cr-00292-PCP Document 44-22 Filed 04/09/25 Page 3 of 6
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 (I) 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 ifthe 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 ofup to $250,000; under 15 USC 645 by imprisonment of not more than two years and/or a fine ofnot 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
DocuSilii\Fegrnm Requirements and all SBA reviews.
~ssit- lJJill-~ 5/20/2020
1gna ure or1eMhorized Representative of Applicant Date
Cassie Will-darnall Partner
Print Name Title
2
SBA Form 2483 (04/20)
US-0000308
US-0000308
DocuSign Envelope ID: 590ABEB6-F87F-41A3-8CEF-764546802B1 D
Case 5:24-cr-00292-PCP Document 44-22 Filed 04/09/25 Page 4 of 6
Paycheck Protection Program
Borrower Application Form
Purpose of this form:
This form is to be completed by the authorized representative of the Applicant and submi,tted 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 thatdeterrninat:ion.
Instructions for completing this form:
With respect to ''purpose of the loan," payroll costs consist of compensation to employees (whose principal place ofresidence 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 hme 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 ammmt of an EIDL made between January 31, 2020
and April 3, 2020, less the ammmt of any "advance" llllder 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 of20% 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 0MB
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. \Vhen 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)(l)(B), 15 USC Section 636(a)(l)(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 ofrecords when this information indicates a violation or potential violation oflaw, 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 backgrolllld checks but only to the extent the information is relevant to
the requesting agencies' function. See, 7 4 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 reflllld 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
SBA Form 2483 (04/20)
US-0000309
US-0000309
DocuSign Envelope ID: 590ABEB6-F87F-41A3-8CEF-764546802B1 D
Case 5:24-cr-00292-PCP Document 44-22 Filed 04/09/25 Page 5 of 6
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. SB A'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 tirings, 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, ilireclors, stockholders or paTtners), the collateral pledged lo secure the loan, the amounl of the loan, ils purpose in general lenns
and the maturity. Proprietary data on a borrower would not routinely be made available to tlrird parties. All requests under tlris Act are to be
addressed to the nearest SBA office and be identified as a Freedom oflnformation 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 tlris 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 ProtectionAct.
Debarment and Suspension Executive Order 12549; (2 CFR Part 180 and Part 2700) - By submitting tlris loan application, you certify
that neither the Applicant or any owner of the Applicant have witlrin 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 oftlris
certification.
4
SBA Form 2483 (04/20)
US-0000310
US-0000310
DocuSign Envelope ID: 590ABEB6-F87F-41A3-8CEF-764546802B1 D
Case 5:24-cr-00292-PCP Document 44-22 Filed 04/09/25 Page 6 of 6
Additional Owners (Continued)
List additional owners of20% or more of the equity of the Applicant.
Owner Name Title Ownership% TIN (EIN, SSN] Address
Additional Owners (Continued)
US-0000311
US-0000311
File and source
- File
- gov.uscourts.cand.430212.44.22.pdf
- Size
- 1,203,094 bytes
- SHA-256
- 64b94be87cbb02bf0f8a1d77307c05e2fc63a4203dc898f81367f07a870b14ee
- Original
- No public link identified.