Plaintiff's Loan Forgiveness Application Form 3508EZ, Exhibit 3 (Case 1:24-cv-00040-DAE, Document 20-3)

Summary

Exhibit 3 to Document 20-3 in Case 1:24-cv-00040-DAE, marked as filed 04/29/24, is headed Plaintiff's Loan Forgiveness Application Form 3508EZ. The form names the borrower as Horseshoe Bay Resort Holdings, LLC and checks First Draw PPP Loan, listing a PPP loan disbursement date of 05/01/2020, 237 employees at the time of loan application and 228 at forgiveness application, and a covered period of 05/01/2020 to 10/15/2020. It lists payroll costs of $4,149,925.00 on line 1 and a PPP loan amount of $2,370,747.50 on line 10. It records a forgiveness amount of $2,370,747.50 on line 12, the smallest of lines 9, 10 and 11.

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 1:24-cv-00040-DAE Document 20-3 Filed 04/29/24 Page1of5

EXHIBIT 3

Plaintiff's Loan Forgiveness Application
Form 3508EZ
Case 1:24-cv-00040-DAE Document 20-3 Filed 04/29/24 Page 2of5

DocuSign Envelope ID: 5500FCDC-298A-43A3-B69C-1F 9CO2ABF909

OMB Control No.; 3245-0407
Expiration Date: 01/31/2022

Paycheck Protection Program
PPP Loan Forgiveness Application Form 3508EZ Revised July 30, 2021
~ Business Legal Name (“Borrower”) DBA or Tradename, if applicable
HORSESHOE BAY RESORT HOLDINGS, LLC —
Business Address NATO Cone | aes TNR SSR TTA) Business Phone
PO BOX 4449 HORSESHOE BAY TX 78657 (830 220- 2324
713910 Contact E-mail Address
JAFFE ASSETS LLC rmitchell@hsbresort.com

XX] First Draw PPP Loan C) Second Draw PPP Loan (check one)

SBA PPP Loan Number:__ 3866357206 Lender PPP Loan Number: _93000001031782

PPP Loan Amount:__$_2.370.747.50 PPP Loan Disbursement Date: _ 05/01/2020
Amount of PPP Loan Increase (if applicable): Date of PPP Loan Increase (if applicable):

Employees at Time of Loan Application: _237 Employees at Time of Forgiveness Application: _228

Covered Period:__ 05/01/2020 _ to __ 10/15/2020

Forgiveness Amount Calculation:

Payroll and Nonpayroll Costs

Line 1. Payroll Costs: $__4,149,925.00
Line 2. Business Mortgage Interest Payments: $ 0,00
Line 3. Business Rent or Lease Payments: $ 0.00
Line 4. Business Utility Payments: $ 0.00
Line 5. Covered Operations Expenditures: “s 0.00
Line 6. Covered Property Damage Costs: $ 0.00
Line 7. Covered Supplier Costs: _$ 0.00
Line 8. Covered Worker Protection Expenditures: $ 0.00

Potential Forgiveness Amounts

Line 9. Sum the amounts on lines | through 8: $ _4,149,925.00
Line 10. PPP Loan Amount: $  2,370,747.50
Line 11. Payroll Cost 60% Requirement (divide Line 1 by 0.60): $ 6,916,541.67

Forgiveness Amount
Line 12. Forgiveness Amount (enter the smallest of Lines 9, 10, and 11): $__2,370,747.50

SBA Form 3508EZ (07/21)
File: caf@@tbrgiveness_sba_3508_ez_29453.pdf [2022/04/28 12:45:54] 31 of 1667
Case 1:24-cv-00040-DAE Document 20-3 Filed 04/29/24 Page 3of5

DocuSign Envelope ID: 5500F CDC-298A-43A3-B69C-1 F9CO2ABF909

Paycheck Protection Program
PPP Loan Forgiveness Application Form 3508EZ Revised July 30, 2021

OMB Control No.: 3245-0407
Expiration Date: 01/31/2022

PPP Borrower Demographic Information (Optional)

Instructions

1. Purpose. Veteran/gender/race/ethnicity data is collected for program reporting purposes only.
2. Description. This form requests information about each of the Borrower’s Principals. Add additional sheets ifnecessary.
3. Definition of Frincival. The term “Principal” means:
For a self-employed individual, independent contractor, or a sole proprietor, the self-employed individual,
independent contractor, or sole proprietor.
* Fora partnership, all general partners and all limited partners owning 20% or more of the equity of the Borrower, or
any partner that is involved in the management of the Borrower’s business.
* For acorporation, all owners of 20% or more of the Borrower, and each officer and director.
* Fora limited liability company, all members owning 20% or more of the Borrower, and each officer and director.
¢ Any individual hired by the Borrower to manage the day-to-day operations of the Borrower (“key employee”).
¢ Any trustor (if the Borrower is owned by a trust).
* For anonprofit organization, the officers and directors of the Borrower.
4. Principal Name. Insert the full name of the Principal.
5. Principal Position. Identify the Principal’s position; for example, self-employed individual; independent contractor;
sole proprietor; general partner; owner; officer; director; member; or key employee.

Select Response Below:

Veteran CNon-Veteran; [] Veteran; ()Service-Disabled Veteran: [J Spouse of Veteran; Not
Disclosed

Gender OMale; (Female; (JNot Disclosed

Race (more than 1} [)American Indian or Alaska Native; DAsian; ()Black or African-American; Native
may be selected) | Hawaiian or Pacific Islander; White; [JNot Disclosed
Ethnicity C)Hispanic or Latino; (JNot Hispanic or Latino; (JNot Disclosed

Disclosure is voluntary and will have no bearing on the loan forgiveness decision

the Following Representations and Certi f of ‘ower:
The Authorized Representative of the Borrower certifies to all of the below by initialing next to each one. The terms “payroll” and
“payroll costs” as used in the below certifications include proprietor expenses (business expenses plus owner compensation) for
Borrowers that applied for loans using SBA Form 2483-C or 2483-SD-C.

The — amount for which forgiveness is requested (which does not exceed the principal amount of the PPP loan):
was used to pay business costs that are eligible for forgiveness (payroll costs to retain employees; business mortgage
interest payments; business rent or lease payments; business utility payments; covered operations expenditures;
covered property damage costs; covered supplier costs; or covered worker protection expenditures);
* — includes payroll costs equal to at least 60% of the forgiveness amount; and
* for any owner-employee (with an ownership stake of 5% or more) or self-employed individual/general partner, does
not exceed 2.5 months’ worth of compensation received during the year used to calculate the PPP loan amount,
capped at $20,833 per individual in total across all businesses.
ML I understand that if the funds were knowingly used for unauthorized purposes, the federal government may pursue recovery
of loan amounts and/or civil or criminal fraud charges.
wl The Borrower did not reduce salaries or hourly wages of any employee by more than 25 percent for any employee during the
Covered Period compared to the most recent quarter before the Covered Period. For purposes of this certification, the term
“employee” includes only those employees that did not receive, during any single period during 2019, wages or salary at an
annualized rate of pay in an amount more than $100,000.
KL The Borrower has accurately verified the payments for the eligible payroll and nonpayroll costs for which the Borrower is
requesting forgiveness.

SBA Form 3508EZ (07/21)
Page 2
File: cares_forgiveness_sba_3508_ez_29453.pdf (2022/04/28 12:45:54] 32 of 1667
Case 1:24-cv-00040-DAE Document 20-3 Filed 04/29/24 Page4of5

DocuSign Envelope ID: 5500FCDC-298A-43A3-B69C-1F 9CO2ABF909
OMB Control No 3245-0407

. Expiration Date: 01/31/2022
Paycheck Protection Program *piranonees

PPP Loan Forgiveness Application Form 3508EZ Revised July 30, 2021

Me

Ja I have submitted to the Lender the required documentation verifying payroll costs, the existence of obligations and service
(as applicable) prior to February 15, 2020. and eligible business mortgage interest payments, business rent or lease payments,
business utility payments, covered operations expenditures, covered property damage costs, covered supplier costs, and
covered worker protection expenditures.

Jt If this application is being submitted for a Second Draw PPP Loan, the Borrower used all First Draw PPP Loan amounts on
os eligible expenses prior to disbursement of the Second Draw PPP Loan.
Jal The information provided in this application and the information provided in all supporting documents and forms is true and

correct in all material respects. I understand that knowingly making a false statement to obtain forgiveness of an SBA-
guaranteed loan is punishable under the law, including 18 U.S.C. 1001 and 3571 by imprisonment of not more than five years
and/or a fine of up to $250,000; under 15 U.S.C. 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 U.S.C. 1014 by imprisonment of not more than
thirty years and/or a fine of not more than $1.000.000.
SAL The tax documents I have submitted to the Lender (if applicable) are consistent with those the Borrower has submitted
or will submit to the IRS and/or state tax or workforce agency. I also understand, acknowledge, and agree that the
Lender can share the tax information with SBA’s authorized representatives. including authorized representatives of
the SBA Office of Inspector General, for the purpose of ensuring compliance with PPP requirements and all SBA
os reviews.
Jal | understand. acknowledge, and agree that SBA may request additional information for the purposes of evaluating the
Borrower's eligibility for the PPP loan and for loan forgiveness, and that the Borrower’s failure to provide information
requested by SBA may result in a determination that the Borrower was ineligible for the PPP loan or a denial of the
Borrower's loan forgiveness application.

mR

In_addition, the Authorized Representative of the Borrower must certify by initialing at least ONE of the following two items:

x ML The Borrower did not reduce the number of employees or the average paid hours of employees between January 1. 2020 and

the end of the Covered Period (other than any reductions that arose from an inability to rehire individuals who were
employees on February 15, 2020, if the Borrower was unable to hire similarly qualified emplovees for unfilled positions on
or before December 31, 2020 (or, for a PPP loan made after December 27, 2020, before the last day of the Covered Period),
and reductions in an employee’s hours that a borrower offered to restore and were refused).
The Borrower was unable to operate between February 15, 2020. and the end of the Covered Period at the same level of
business activity as before February 15, 2020 due to compliance with requirements established or guidance issued between
March 1, 2020 and December 31, 2020 (or, for a PPP loan made atter December 27, 2020, requirements established or
guidance issued before the last day of the Covered Period), by the Secretary of Health and Human Services, the Director of
the Centers for Disease Control and Prevention, or the Occupational Safety and Health Administration, related to the
maintenance of standards of sanitation, social distancing, or any other work or customer safety requirement related to
COVID-19.

The Borrower's eligibility for loan forgiveness will be evaluated in accordance with the PPP regulations and guidance issued by SBA
through the date of this application. SBA may direct a lender to disapprove the Borrower’s loan forgiveness application if SBA
determines t that the Borrower was ineligible for the PPP loan.

MEFE ASSETS UL 9/24/2021
tUFE CTA uthorized Representative of Borrower Date
JAFFE ASSETS LLC Member

Print Name Title

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 20 minutes. Comments about this time or the
information requested should be sent to Small Business Administration. Director, Records Management Division, 409 3rd St.. SW, Washington DC
20416, and/or SBA Desk Officer, Office of Management and Budget, New Executive Office Building, Washington DC 20503. PLEASE DO NOT
SEND FORMS TO THESE ADDRESSES.

SBA Form 3508EZ (07/21)
Page 3

File: cares_forgiveness_sba_3508_ez_29453.pdf [2022/04/28 12:45:54] 33 of 1667
Case 1:24

-cv-00040-DAE Document 20-3

DocuSign Envelope ID: SSO0FCDC-298A-43A3-B69C-1F9CO2ABF909

PPP Borrower D raphic Information (Optional

Instructions: Capture additional principals (if needed)

Filed 04/29/24 Page5of5

Veteran

1=Non- Veteran; 2=Veteran; 3~Service-Disabled Veteran; 4=Spouse of Veteran; X=Not

Gender

X=Not Disclosed

Race (more than |
|_may be selected) _

1=American Indian or Alaska Native, 2~Asian; 3=Black or African-American; 4=Native
Hawaiian or Pacific Islander; 5~White; X~Not Disclosed

Ethnicity

| H=Hispanic or Latino; N=Not Hispanic or Latino; X=Not Disclosed

Disclosure is voluntary and will have no bearing on the loan forgiveness decision

Veteran

1=Non- Veteran; 2= Veteran; 3~Service-Disabled Veteran; 4=Spouse of Veteran; X=Not
Disclosed

| Gender
Race (more than |

/M=Male; P=Female, X=Not Disclosed

t=American Indian or Alaska Native; 2=Asian; 3=Black or African-American; 4=Native
Hawaiian or Pacific 5=White; X=Not Disclosed

| may be selected) _
| Echnicity

_ Hawaiian or Pacific Islander, ~White;

Disclosure is voluntary and will have no bearing on the loan forgiveness decision

[ Principal Name

Veteran

1=Noo- Veteran; 2=Veteran; 3=Service-Disabled Veteran; 4=Spouse of Veteran; X=Not

| Gender
Race (more than |

M=Male; F=Female; X=Not Disclosed

1=American Indian or Alaska Native; 2=Aaian: 3-Black or Alfican-Amers Nati
Hawaiian or Pacific Islander, ; X=Not Disclosed

| may be selected) _|
Ethnicity

H=Hispanic or Latioo, N=Not Hispanic or Latino, X=Not Disclosed

Disclosure is voluntary and will have no bearing on the loan forgiveness decision

| Principal Name

Veteran

1=Non-Veteran; 2= Veteran; 3~Service-Disabled Veteran; 4=Spouse of Veteran; X=Not
Disclosed

Gender

Race (more than |
| may be selected) |
| Ethnicity

X=Not Disclosed

1=American Indien or Alaska Native; 2~Asian; 3=Black or African-American; 4=Native

Hawaiian or Pacific Islander, S=White; X=Not Disclosed
H=Hispanic or Latino; N=Not Hispanic or Latino; X=Not Disclosed

Disclosure is voluntary and will have no bearing on the loan forgiveness decision

Veteran

1=Non- Veteran; 2=Veteraa; 3=Service-Disabled Veteran; 4~Spouse of Veteran; X=Not
Disclosed

| Gender

Race (more than |
may be selected) _
[Ethnicity |

Disclosure is voluntary and will have no bearing on the loan forgiveness decision

X=Not Disclosed

1=American Indian or Alaska Native; 2~Asian; }=Black or African-American; 4=Native
Hawaiian or Pacific Islander, X=Not Disclosed

| He-Hispanic or Latino; N=Not Hispanic or Latino; X=Not Disclosed

Complete

File: cares_forgiveness_sba_3508_ez_29453.pdf [2022/04/28 12:45:54]

34 of 1667

File and source

File

horseshoe_bay_resort_holdings_sba__docket-68151891__doc-20_att-3__id-467909737__Appendix.pdf

Size

2,136,079 bytes

SHA-256

7cbc7aa810def133bd29bea02e3a5750d9a0202ef954976d083eec00a5494e8e

Our copy

horseshoe_bay_resort_holdings_sba__docket-68151891__doc-20_att-3__id-467909737__Appendix.pdf

Original

storage.courtlistener.com