SAMPLE COVID EIDL Application (This is a Sample only)
Summary
Sample SBA COVID-19 Economic Injury Disaster Loan application, OMB Control #3245-0406, marked as a sample only. Its disclosures say SBA collects the information to make loans under its Economic Injury Disaster Loan Program to qualified entities affected by the Coronavirus (COVID-19), and that an incomplete application cannot be fully processed. The applicant acknowledges that SBA relies on the self-certifications in the application to verify eligibility. The sample then shows the sections for business information, business owners information, additional information and a summary, along with streamlined process requirements.
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
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I I OMB OMControl #3245-0406
B Control #3245-0406
U.S. Small Bus.ioes.s Expiration Date: MM/DD/YYYY OMB
Adrni ni;t r;iti on Expiration Date: 02/28/2022
Expiration Date: 11/30/ 2023
Disaster Loan Assistance
Federal Disaster Loans for Businesses, Private Non-profits, Homeowners and Renters
COVID-19 ECONO MIC INJURY DISASTER LOAN APPLICATION
D ISCLOSURES
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l,j I
BU SINESS INFORMATION
...•
BUSIN ESS DWNERS INFORMAT ION
i!i
ADDI TI ONAL INFORMATION
r.i
SUMMARY
STREAMLINED PROCESS REQUIREMENTS
SBA is collecting the requested information in order to make a loan under SBA s Economic Injury Disaster Loan Program to the qualified entities listed in this
application that are impacted by the Coronavirus (COVID-19). The information will be used in determining whether the applicant is eligible for an economic injury
loan. If you do not submit all the information requested, your loan cannot be fully processed.
The Applicant understands that the SBA is relying upon the self-certifications contained in this application to verify that the Applicant is an eligible entity, and that
the Applicant is providing this self-certification under penalty of perjury pursuant to 28 U.S.C. 1746 for verification purposes.
The estimated time for completing this entire application is one hour and fifteen minutes, although you may not need to complete all parts. You are not required to
respond to this collection of information unless it displays a currently valid OMB approval number.
ELIGIBLE ENTITY VERIFICATION
Choose One:
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0
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Applicant is a business that, together with affiliates, has not more than 500 employees.
Applicant is an agricultural enterprise that, together with affiliates, has not more than 500 employees.
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Applicant is an individual who operates under a sole proprietorship, with or without employees, or as an independent contractor and, together with affiliates has
not more than 500 employees.
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Applicant is a cooperative that, together with affiliates, has not more than 500 employees.
Applicant is a tribal small business concern, as described in 15 U.S.C. 657 a(b)(2)(C), that has not more than 500 employees.
Applicant is a business, including an agricultural cooperative, aquaculture enterprise, nursery, or producer cooperative (but excluding all other agricultural enterprises),
with more than 500 employees that is small under SBA Size Standards found at https:// www.sba.gov/size-standards.
Applicant is a private non-profit organization that is a non-governmental agency or entity that currently has an effective ruling letter from the IRS granting tax exemption
under sections 501(c), (d), or (e) of the Internal Revenue Code of 1954, or satisfactory evidence from the State that the non-revenue producing organization or entity is a
non-profit one organized or doing business under State law, or a faith-based organization.
Applicant is a business that, together with affiliates, has more than 500 employees and:
-is assigned a NAICS code beginning with 61, 71, 72, 213, 3121, 315, 448, 451, 481, 485, 487, 511, 512, 515, 532 or 812;
M
-employs not more than 500 employees per physical location; and
-has no more than 20 locations.
ELIGIBILITY QUESTIONS:
Applicant must review and respond to all of the following questions . Please note that "owner" includes each proprietor, each limited partner or LLC
member who owns 20% or more interest, each general partner or managing member, and each stockholder or entity owning 20% or more voting stock.
If you answer "Yes" to questions 1-18 or 20, the Applicant is not eligible.
SA 1. Is any principal of the Applicant with 50 percent or greater ownership interest more than sixty (60) days delinquent on child support obligations? *
( ' No (' Yes
2. Has Applicant or owners of Applicant ever been engaged in the production or distribution of any product or service that has been determined to be obscene by a
court of competent jurisdiction? *
( ' No (' Yes
3. Is Applicant or owners of Applicant currently suspended or debarred from contracting with the Federal government or receiving Federal grants or loans? *
No Yes
4. Is any owner of the Applicant currently incarcerated? *
(' No (' Yes
5. Is any owner of the Applicant presently subject to an indictment, criminal information, arraignment, or other means by which formal criminal charges are brought
in any jurisdiction for any felony? *
( ' No (' Yes
6. Within the last 5 years, for any felony involving fraud, bribery, embezzlement, or a false statement in a loan application or an application for federal financial
assistance, has any owner of the Applicant 1) been convicted; 2) pleaded guilty; 3) pleaded nolo contendere; or 4) commenced any form of parole or probation
(including probation before judgment)? *
( No ( Yes
7. Is Applicant engaged in any illegal activity (as defined by Federal guidelines) including selling recreational or medical marijuana? *
C No (' Yes
8. Does Applicant present live performances of a prurient sexual nature or derived directly or indirectly more than de minimis gross revenue through the sale of
products or services, or the presentation of any depictions or displays, of a prurient sexual nature? *
( ' No (' Yes
9. Does Applicant derive more than one-third of gross annual revenue from legal gambling activities? *
( ' No (' Yes
10. Is Applicant primarily engaged in political or lobbying activities? *
' No ~ Yes
11. Is Applicant owned by a state, local, or municipal government entity (other than a tribal business concern, as described in 15 U.S.C. 657a (b)((2)(C))? *
(' No (' Yes
12. Is Applicant owned by a member of Congress? *
(' No (' Yes
13. Is Applicant a pawn shop that derived more than 50% of the previous year 's income from interest? *
( ' No (' Yes
14. Is Applicant engaged in lending or investment? *
( ' No (' Yes
15. Is Applicant a loan packager that earns more than one-third of its gross annual revenue from packaging SBA loans? *
0 No ') Yes
16. Is Applicant engaged in multi-level sales distribution? *
( ' No (' Yes
17. Is Applicant engaged in real estate development or investment (other than rental properties)? *
( ' No (' Yes
18. Is Applicant a life insurance company? *
(' No (' Yes
19. Is the Applicant business (or the owner, if the business is a sole proprietor or an independent contractor) currently in bankruptcy? *
( ) No (Applicant is eligible)
0 Yes - Operating under an approved plan of reorganization under either a Chapter 11, Chapter 12 or Chapter 13 bankruptcy (Applicant is eligible)
0 Yes – Filed for either a Chapter 11, Chapter 12 or Chapter 13 bankruptcy but no plan of reorganization has been approved (Applicant is not eligible)
0 Yes – Filed for a Chapter 7 bankruptcy, is undergoing a liquidating Chapter 11, and/or is permanently closed (Applicant is not eligible)
20. In the past year, has any owner of Applicant been convicted of a felony committed during and in connection with a riot or civil disorder or other declared disaster? *
( ' No (' Yes
21. Did you receive compensation from other sources as a result of the disaster (e.g. Paycheck Protection Program, Restaurant Revitalization Fund, etc)?*
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If yes, provide a description of the compensation source and amount received.
If you hav e q u estions abo u t t h is applicat io n o r p rob le m s p rovid ing t h e req uired i nfo r m at io n, please co ntact o ur Custome r Se rv ice Ce n t e r at 1-800-659-2955 o r (TTY: 1 -800-877-
8339) Disast erCustom er Serv ice@sba .gov.
Continue >
SBA Office ofD isarte r As5 i rt<l ncoE I 1-800-659-2955 [ 409 3rd st, SW. W<15h i ngton, DC20416
Pr ivacy Policy
I I 0 MB Control #3245-0406
Expiration Date: MM/DD/YYYY OMB Control #3245-0406
SBAI
I
U.S. Small Business
Administration
Expiration Date:
Expi 02/28/2022
ration Date: 11/ 30/ 2023
Disaster Loan Assistance
Federal Disaster Loans for Businesses, Private Non-profits, Homeowners and Renters
COVID-19 ECONOM IC INJURY DISASTER LOAN APPLICATION
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DISCLOSURES BUSINESS INFORMATION BUSINESS OWNERS INFORMATION ADDITIONAL INFORMATION SUMMARY
Step l of 3
Business Information
Business Legal Name * (Sole proprietors or independent contractors without a legal business name should use the owner s name)
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Trade Name (Enter DBA name if different than legal name)
Organization Type *
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Is the Applicant a tribal small business concern? *
~ ~
'- No '- Yes
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Please select which form was used for the Applicant business s 2019 tax return: *
Business TIN Type *
E V
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EIN
SSN
Business TIN (EIN/SSN) *
Is the Applicant a Franchise? *
C' No @ Yes
PL
SBA Franchise Identifier Code (Search for your code at https://www.sba.gov/document/support-sba-franchise-directory) *
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Primary Business Location
Primary Business Address {Cannot be P.O. Box) •
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City •
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SA
State •
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County
Zip •
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Business Mailing Address is the same as Business Location Address
Business Mailing Address
Business Address *
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City •
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State •
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Zip •
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Additional Business Data
Business Phone •
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Alt ernative Business Phone
Business Fax
Business Ema il •
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Date Business in Operation (Began making sales) *
I mm/dd/ yyyy
Cu rrent Owners hip Since •
I mm/dd/ yyyy
Business Activity •
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Detailed Bus iness Activity*
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NAICS Code (Search for your applicable code at https://www.naics.com/search) *
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Number of Employees {As of January 31, 2020) •
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Current Number of Employees *
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Business Financial Data
Actual 2019 Gross Receipts or Sales *
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Actual 2019 Cost of Goods Sold (may be $0)*
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Actual 2020 Gross Receipts or Sales *
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Actual 2020 Cost of Goods Sold (may be $0) *
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Rental Properties (Residential and Commercial) Only – Actual 2019 rents
Rental Properties (Residential and Commercial) Only – Actual 2020 rents
Non-profit or Agricultural Enterprise – Actual 2019 Cost of Operation
Non-profit or Agricultural Enterprise – Actual 2020 Cost of Operation
Calculated Eligible Loan Amount
Applicant Requested Loan Amount
SBA Office of Disaster Assistance I 1·800-659-295S I 409 3rd St, SW. Washington, DC 20416
Privacy Policy
I OMB Control
0 MB #3245-0406
Control #3245-0406
SBAI
I
U.S. Small Business
Administration Expiration Date:Date:
Expiration 02/28/2022
11/ 30/ 2023
Disaster Loan Assistance
Federal Disaster Loans for Businesses, Private Non-profits, Homeowners and Renters
COVID-19 ECONOM IC INJURY DISASTER LOAN APPLICATION
Ii
DISCLOSURES BUSINESS INFORMATION BUSINESS OWNERS INFORMATION ADDITIONAL INFORMATION SUMMARY
Step 2 of 3
Business Owners Information
Is the Applicant Business Owned by a Business Entity? * No @ Yes
Business Applicant Parent Entity A
Legal Name •
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Organization Type *
I V
Business TIN Type *
I V
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Business TIN (EIN/SSN) *
Street Address •
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City •
State •
Zip *
PL V
Business Phone •
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Business Email •
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Ownership Percent •
M
SA
If a Business Applicant is own ed by a business ent ity, t hat business ent ity must provide information as part of t his applicat ion and must sign a guarantee.
Individual Owner(s)
Complete for Each : a. Proprieto r, orb. Lim ited partne r o r LLC m e mber w ho ow ns 20% o r m o re inte rest an d each gene ra l p artne r or man ag ing m embe r, o r c. Stockho lder o r
e ntity own ing 20% o r more voting sto ck.
Owner1
First Name •
A
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Last Name •
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Mobile Phone •
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Tit le / Office •
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Ownership Percent •
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Email •
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SSN •
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Birth Date •
I mm/dd/ yyyy
Place Of Birth
Is Owner U.S. citizen, non-citizen national1, or qualified alien 2 ? *
( ' No (' Yes
Resident ial St reet Address •
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City •
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State •
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Zip •
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[ :,.+ Add Addi tiona l Owner
1 Non-( it i7Pn N;itio n;i isrJpfinP<l in P. l l .S.C:. 1408: l ln lpss ot hPrviisP providPrl in P, l J.S.C:. 1401, t hP fo ll owing sh;i ll hP n;it ion;il,, h11• not ,iti7Pns, 11f thP l Jnit?rl St;itps ;it hirth:
a. A person bo rn in on ,) utlying poS!le,sion o f t he United States o n ornftcr t he dote of forma l acq uisitio n of su ch possessio n;
b. A person bo rn outside th e United State; a nd itsoutlying possessi onsof pa rents both of whom are nat ion als, b Jtnotcitizens,ofthe United States, and nave had a
res·dence in the Un ited States, o r on e o f its outlying possession; prior to the birth of such perso1;
r . A r,?rson of 1m knr,w n p;irpnt;igp fo11 nrJ in an n11tlying rossP~sion o f t hP l JnitPrl St atFs whilP 1,nrJpr thP ;igp of fivP yPa rs, 1mfl shown, prior to h is ;itt;iinine t hP ag? r,f
twenty on~ years, not to hove been born in such outlying possession; 01d
d. A person bo rn outside th e United State; a nd its o ut lying possessi ons o f pa rents o ne o f Whom is an alien, and t he other a national, b ut not a citizen, o f t he United States
who, prio r to t he birth of su: h perso n, was physica lly present in t he Un ited States o · its outlying possessions for a pe r'od or periods to ta ling not less than seven years in
any continuou s period o f ten years.
1. During which the natio nal p arent was no t outsi de t he United States o r it s out lying possessions for a continuous pe riod of m ,x e t han c ne y ea r, and
2. ALledsl ri·, e years u f wllicll wc1e arLe1 ollci11i11g Lhe a!;e or ru ui Lee n yea1s.
2Qu alified Alien is defi ned in 8 U.S.C 1(4 1(b) and (c): The term "q ua lified a lie n" means an alien who, at the time the elien applies for, receives, or attempts t o receive a red era l
p ublic benefit, is;
a. An alien w ho is lawfully admitted for perma nent resid en ce Jnd er the Immigratio n and Natio nality Act (3 U.S.C. 1101 et SeQ.),
b. An alien w ho is g ranted asylu m unde r 8 U.S.C. 1158,
c. A refugee who is adnitted to th e United States under E- U.S.C.11!:i7.
d. An alien w ho is paro led into the United States under 8 U.5.C. llbl(d}(!,) fo r a period o f at least 1 yea r,
e. An alien w ho se deportation is being withhe ld under 8 U.S.C. 1253 (as in effect imm ed iately before th e effecfve date o' § 307 of division C o f Pub lic Law : 04- 208) o r §
241(bl (3) of such Act (8 U. S.C.1231 (b)(3)] (as amen ded by§ 305(ai of d ivisic n C of Public Law 104- 208),
f. An alien w ho is g ranted C>) nd itio1al e1try pursuant to 8 U.S.C. 11!:i3 (a)(?) as in effect prior to April 1, 1980;
g. An alien w ho is a Cuban an d Haitia1 entrant (a; defi 1e£1 in § !,1J1(e) o f t he Refu gee Education Assista nce Act of 1Y8U); or
h. An alien w ho has been battered o r , u oj ected toer.tre me cr uelty, o r a victi m of hu man trafficking (see 8 U.S.C. 1641(c) fo r d etails).
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SBA Office of Disaster Assistance I 1·800-659·2955 I 409 3rd St, SW. Washington, DC 20416
Privacy Policy
IJ.S. Small Bu si ness OMBOM
Control #3245-0406
B Control #3245-0406
Admi nistration
Expiration Date:Date:
Expiration 02/28/2022
11/30/2023
Disaster Loan Assistance
Federal Disaster Loans for Businesses, P,r ivate Non-profits, Homeowners and Renters
COVID-19 ECONO MIC INJURY DISASTER LOAN APPLICATION
DISCLOSURES
-
I.I I
BUSINESS INFORMATION
,.
Iii
BUSINESS OWNERS INFORMATION ADDITIONAL IN FORMATION SUMMARY
Step 3 of 3
Additional Information
REQUIRED DOCUMENTATION (These documents will be requested online later in the process. Your application will not be accepted without
REQUIRED DOCUMENTATION (Application will not be accepted without the following):
them):
IRS Form 4506-T, completed and signed by Applicant. Completion of this form digitally on the SBA COVID EIDL Platform will satisfy this requirement .
Any of the following documents demonstrating gross receipts and/or rental loss (if applicable):
Business tax returns (IRS Form 1120, IRS 1120-S, IRS 1120-C, IRS 990);
IRS Forms 1040 Schedule C; IRS Forms 1040 Schedule F;
For a partnership: partnership s IRS Form 1065 (including K-1s).
ADDITIONAL INFORMATION MAY BE NECESSARY TO PROCESS YOUR APPLICATION. IF REQUESTED, PLEASE PROVIDE WITHIN 7 DAYS OF
THE INFORMATION REQUEST:
Copy of government-issued photo identification of each principal owning 20 percent or more of the applicant business
E
PL
Tax Information Authorization (IRS Form 4506T), completed and signed by each applicant, each principal owning 20 percent or more of the applicant
business, each general partner or managing member; and, for any owner who has greater than 50 percent ownership in an affiliate business.
Affiliates include, but are not limited to, business parents, subsidiaries, and/ or other businesses with common ownership or management
Complete copy, including all schedules, of the business's or organization's most recent tax return, or a copy of the organization's IRS tax-exempt
certifications and complete copies of the three most recent year of "Statement of Activities"
If the most recent Federal income tax return has not been filed, a year-end profit-and-loss statement and balance sheet for that tax year
Current year-to-date profit-and-loss statement
Schedule of Liabilities listing all fixed debts (SBA Form 2202 may be used)
If anyone assisted you in completing this application, whether you paid a fee for this service or not, that person must enter their information below.
Individ ual Name
Name of Company
Phone Number
M
SA
Street Address, City, State, Zip
Fee Charged or Agreed Upon
I give pe rm iss ion fo r SBA l o d iscuss any portion of this a pplicat ion wit h t he rep resentative listed a bove. No r Yes
Where to Send Funds
Bank name should be the official name of the bank; please contact your bank if you are unsure. Ensure that you provided a checking account to facilitate the ACH payment. The bank account
you provide must satisfy the following: (1) Account opened using your business legal name matching the values entered in the business information section of this application. If you do not
have a business legal name, the name on the account must match the business owner's name; (2) Account has your business address and phone number; (3) Account opened using your
business tax identification number (EIN or SSN).
Bank Name •
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Routing Number *
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Account Number *
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On behalf of the individual owners identified in this application and for the business applying for the loan :
I/We authorize my/our insurance company, bank, financial institution, or other creditors to release to SBA all records and information necessary to process this
application and for the SBA to obtain credit information about the individuals completing this application .
If my/our loan is approved, additional information may be required prior to loan closing. I/We will be advised in writing what information will be required to obtain
my/our loan funds. I/We hereby authorize the SBA to verify my/our past and present employment information and salary history as needed to process and service
a disaster loan. I/We authorize SBA, as required by the Privacy Act, to release any information collected in connection with this application to Federal , state, local,
tribal or nonprofit organizations (e.g., Red Cross Salvation Army, Mennonite Disaster Services, SBA Resource Partners) for the purpose of assisting me with my/our
SBA application, evaluating eligibility for additional assistance, or notifying me of the availability of such assistance.
I/We will not exclude from participating in or deny the benefits of, or otherwise subject to discrimination under any program or activity for which I /we receive
Federal financial assistance from SBA, any person on grounds of age, color, handicap, marital status, national origin, race, religion, or sex.
I/We will report to the SBA Office of the Inspector General, Washington, DC 20416, any Federal employee who offers, in return for compensation of any kind, to
help get this loan approved. I/We have not paid anyone connected with the Federal government for help in getting this loan .
CERTIFICATION AS TO TRUTHFUL INFORMATION: By signing this application, you certify that all information in your application and submitted with your application
is true and correct to the best of your knowledge, and that you will submit truthful information in the future.
WARNING: Whoever wrongfully misapplies the proceeds of an SBA disaster loan shall be civilly liable to the Administrator in an amount equal to one-and-one half
times the original principal amount of the loan under 15 U.S.C. 636(b). In addition, any false statement or misrepresentation to SBA may result in criminal, civil or
administrative sanctions including, but not limited to: 1) fines and imprisonment, or both, under 15 U.S.C. 645, 18 U.S.C. 1001, 18 U.S.C. 1014, 18 U.S.C. 1040, 18
U.S.C. 3571, and any other applicable laws; 2) treble damages and civil penalties under the False Claims Act, 31 U.S.C. 3729; 3) double damages and civil penalties
under the Program Fraud Civil Remedies Act, 31 U.S.C. 3802; and 4) suspension and/or debarment from all Federal procurement and non-procurement
transactions. Statutory fines may increase if amended by the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015.
[ I t.ereby certify UNDER PENALTY OF PERJURY UND :ER THE LAWS OF THE UNIT ED STATES that the above is true and correct.
Click fo r addit ional statements req uired by laws and execut ive orders
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SBA Office ofDisaster Assistance I 1-800-659-295.5 I 409 3rd st, SW. Washington, DC 20416
Priv acy Policy
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