Form SBA Form 4 SBA Form 4 Application for Business Loans

OMB Approval No. 3245-0016 E xpiration Date: U. S. Small Business Administration APPLICATION FOR BUSINESS LOAN (SUBMIT COMPLETED APPLICATION TO LENDER OF CHOICE.)

Individual

Full Address

Name of Applicant Business

Tax I.D. No. or SSN

Full Street Address of Business

Tel. No. (inc. Area Code)

City

County

State

Zip

Number of Employees (including subsidiaries and affiliates) At Time of Application _______ If Loan is Approved _______ Subsidiaries or Affiliates _______ (Separate for above)

Type of Business

Date Business Established

Bank of Business Account and Address

Use of Proceeds: (Enter Gross Dollar Amounts Rounded to the Nearest Hundreds)

Loan Requested

Loan Request

Land Acquisition

Pay off SBA Loan

New Construction/ Expansion Repair

Pay off Bank Loan (Non SBA Associated)*

Acquisition and/or Repair of Machinery and Equipment

Other Debt Payment (Non SBA Associated)*

Inventory Purchase

All Other

Working Capital (including Accounts Payable)

Total Loan Requested

Acquisition of Existing Business

Term of Loan - (Requested Maturity)

Yrs.

CURRENT AND PREVIOUS SBA AND OTHER GOVERNMENT DEBT: Complete the chart below if you, your business, any principal of your business, any affiliate of your business, any other business currently owned by a principal, or any business previously owned by you or a principal of your business has received or applied for any direct or guaranteed financial assistance from the Federal Government, including student loans and disaster loans. All current, previous, and pending Government debt must be listed, including loans that have been paid in full or those that resulted in a loss to the Government. (Note: Loans that resulted in a loss to the Government include loans that were charged off, compromised, or discharged as a result of bankruptcy. The amount of the loss is the outstanding principal balance of the loan that the Government had to write off after all collection activities (including compromise) were finalized.)

Agency Name

Borrower’s Name

Original Amount of Loan

Date of Application

Loan Status

Outstanding Balance

$ Amount of Loss to the Government.

Loan #

1.

$

$

$

#

2.

$

$

$

#

3.

$

$

$

#

4.

$

$

$

#

ASSISTANCE: Did you commit to pay -- or have you paid -- anyone (including the lender) to assist you in either obtaining this loan (such as a broker, consultant or referral agent) or in preparing the application or application materials for this loan (such as a loan packager)? Yes  No  If “yes,” complete SBA Form 159 (7a) – (Fee Disclosure Form and Compensation Agreement) for each party that was paid or will be paid.)

Note: The estimated burden completing this form is 12.0 hours per response. You will not be required to respond to collection of information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to the U.S. Small Business Administration, Chief, AIB, 409 3rd St., S.W., Washington, DC. 20416 and Desk Office for Small Business Administration, Office of Management and Budget, New Executive Building, room 10202 Washington, D.C. 20503. OMB Approval (3245-0016). PLEASE DO NOT SEND FORMS TO OMB.

ALL EXHIBITS MUST BE SIGNED AND DATED BY PERSON SIGNING THIS FORM

BUSINESS INDEBTEDNESS: Furnish the following information on all outstanding installment debts, contracts, notes, and mortgages payable. Indicate by an asterisk (*) items to be paid by loan proceeds and reasons for paying them. (Present balance should agree with the latest balance sheet submitted).
To Whom Payable	Original Amount	Original Date	Present Balance	Rate of Interest	Maturity Date	Monthly Payment			Security	Current or Past Due
	$		$			$
Acct. #
	$		$			$
Acct. #
	$		$			$
Acct. #
Acct. #	$		$			$
Acct. #	$		$			$
MANAGEMENT (Proprietor, partners, officers, directors, all holders of outstanding stock –100% of ownership must be shown.) Use separate sheet if necessary.
Name and Social Security Number Position/Title		Complete Address					% Owned
								*Veteran Status Veteran Yes No If yes, service-disabled? Yes No			*Gender
*Race : Amer. Indian or Alaska Native Asian  Black or African-Amer. Native Haw.or Pacific Islander White								*Ethnicity: Hispanic or Latino Not Hisp or Latino
								*Veteran Status Veteran Yes No If yes, service-disabled? Yes No			*Gender
*Race : Amer. Indian or Alaska Native Asian  Black or African-Amer. Native Haw.or Pacific Islander White								*Ethnicity: Hispanic or Latino Not Hisp or Latino
								*Veteran Status Veteran Yes No If yes, service-disabled? Yes No			*Gender
*Race : Amer. Indian or Alaska Native Asian  Black or African-Amer. Native Haw.or Pacific Islander White								*Ethnicity: Hispanic or Latino Not Hisp or Latino
								*Veteran Status Veteran Yes No If yes, service-disabled? Yes No			*Gender
*Race : Amer. Indian or Alaska Native Asian  Black or African-Amer. Native Haw.or Pacific Islander White								*Ethnicity: Hispanic or Latino Not Hisp or Latino
*This data is collected for statistical purposes only. It has no bearing on the credit decision. Disclosure is voluntary. One or more boxes for race may be selected.

THE FOLLOWING EXHIBITS MUST BE COMPLETED WHERE APPLICABLE. ALL QUESTIONS ANSWERED ARE MADE A PART OF THE APPLICATION.

For Guaranty Loans please provide an original and one copy (Photocopy is Acceptable) of the Application Form and all Exhibits to the participating Lender. For Direct Loans submit one original copy of the application and Exhibits to SBA.

1.Submit SBA Form 912 (Statement of Personal History) for each proprietor (if sole proprietorship), partner (if a partnership), and by each officer, director, and owner of 20% or more of the company’s stock (if a corporation, limited liability company or development company).

2. If your collateral consists of (A) Land and Building, (B) Machinery and Equipment, (C) Furniture and Fixtures, (D) Accounts Receivable, (E) Inventory, (F) Other, please provide an itemized list that contains serial and identification numbers for all articles that had an original value of greater than $5,000. Include a legal description of Real Estate offered as collateral. Label it Exhibit A.

3. Furnish a signed current personal financial statement (SBA Form 413 may be used for this purpose) for (1) each proprietor; or (2) each limited partner who owns 20% or more interest and each general partner; or (3) each stockholder owning 20% or more of voting stock. Include the assets and liabilities of the spouse and any minor children.

Also, include the tax i.d. number [EIN or Social Security Number (SSN)] Label it Exhibit B.

4. Include the financial statements listed below: a, b, c for the last three years; also a, b, c, and d as of the same date, - current within 90 days of filing the application; and statement e, if applicable. All information must be signed and dated. (a) Balance Sheet; (b) Profit and Loss Statement (if not available, explain why and substitute Federal income tax forms); (c) Reconciliation of Net Worth; (d) Aging of Accounts Receivable and Payable (summary); (e) Projection of earnings for at least one year where financial statements for the last three years are unavailable or when SBA requests them. Label it Exhibit C. (Contact SBA for a referral if assistance with preparation is wanted.)

5. Provide a brief history of your company and a paragraph describing the expected benefits it will receive from the loan. Label it Exhibit D.

6. Provide a brief description similar to a resume of the education, technical and business background for all the people listed under Management. Label it Exhibit E.

SUBMIT COMPLETED APPLICATION TO LENDER OF CHOICE.

7. Submit the name, addresses, tax I.D. number (EIN or SSN), and current personal financial statement of any co-signers who are not otherwise affiliated with the business and any guarantors for the loan not covered by 3. above. Exhibit F.

8. Include a list of any machinery or equipment or other non-real estate assets to be purchased with loan proceeds and the cost of each item as quoted by the seller. Include the seller’s name and address. Exhibit G.

9. Have you or any officer of your company ever been involved in bankruptcy or insolvency proceedings? [ ]Yes [ ]No. If yes, please provide the details as Exhibit H.

10. Are you or your business involved in any pending lawsuits? [ ]Yes

[ ]No. If yes, provide the details as Exhibit I.

11.Do you or your spouse or any member of your household, or anyone who owns, manages, or directs your business or their spouses or members of their households work for the Small Business Administration, Small Business Advisory Council, SCORE or ACE, any Federal Agency, or the participating lender? [ ]Yes [ ]No. If yes, please provide the name and address of the person and the office where employed. Label this Exhibit J.

12. Does your business, its owners or majority stockholders own or have a controlling interest in other businesses? [ ]Yes [ ]No. If yes, please provide their names and the relationship with your company along with financial data requested in question 4. Label this Exhibit K.

13. Do you buy from, sell to, or use the services of any concern in which someone in your company has a significant financial interest? [ ]Yes

[ ]No. If yes, provide details on a separate sheet of paper. Exhibit L.

14. Is your business a franchise? [ ]Yes [ ]No. If yes, include a copy of the franchise agreement and a copy of the FTC disclosure statement supplied to you by the Franchisor. Label this Exhibit M.

CONSTRUCTION LOANS ONLY

15. Include as a separate exhibit the estimated cost

of the project and a statement of the source of any additional

funds. Label this Exhibit N.

16. Provide copies of preliminary construction plans and specifications. Label this as Exhibit 0. Final plans will be required prior to disbursement.

EXPORT LOANS

17. Does your business currently export, or will it start exporting, pursuant to this loan (if approved) ?

Check here: [ ]Yes [ ]No

18. If you answered yes to item 17, what is your estimate of the total export sales this loan would support? $_______________

19. Would you like information on Exporting?

Check here: [ ]Yes [ ]No

_

COUNSELING/TRAINING

20. Have you received counseling or training from SBA (e.g., SCORE, ACE, SBDC, WBC, etc.) ?

Check here: [ ]Yes [ ]No

________________________

____________________________________

AGREEMENTS AND CERTIFICATIONS

AGREEMENTS:

By signing below you agree to the following:

(a) Agreements of non‑employment of SBA Personnel. I agree that if SBA approves this application I will not, for at least two years, hire as an employee or consultant anyone that was employed by the SBA during the one year period prior to the loan disbursement.

(b) Waiver of Claims. As consideration for any Management, Technical, and/or Business Development Assistance that may be provided, I waive all claims against SBA and its consultants.

(c) Criminal Background. I authorize the SBA’s Office of Inspector General to request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for assistance under the Small Business Act.

(d) Reimbursement of Expenses. I agree to pay for or reimburse SBA for the cost of any surveys, title or mortgage examinations, appraisals, credit reports, etc., performed by non‑SBA personnel provided I have given my consent.

(e) Reporting. I agree to report to the SBA Office of the Inspector General, Washington, DC 20416 any federal government employee who offers, in return for any type of compensation, to help get this loan approved.

R EAD THE FOLLOWING CAREFULLY -- FALSE STATE-MENTS ARE SUBJECT TO CRIMINAL PROSECUTION:

If you knowingly make a false statement, you can be fined up to $250,000 and/or imprisoned for not more than five years under 18 USC 1001; if submitted to a Federally insured institution, under 18 USC 1014 by Imprisonment of not more than twenty years and/or a fine of not more than $1,000,000

CERTIFICATIONS:

By signing below you certify as to the following:

(a) All information in this Application and the Exhibits is true and complete to the best of your knowledge. You understand that this information is being submitted to a lender and SBA so they can decide to make a loan or give a loan guaranty, and that the lender and SBA are relying on this information.

(b) You have not paid anyone employed by the Federal Government for help in getting this loan. You understand that you do not need to pay any other third-party for assistance in locating a lender or preparing this Application or Exhibits, and you certify that you will disclose all parties that were paid for such assistance to the Lender and will complete the SBA Form 159 for all such persons.

(c) I have read a copy of the "Statements Required By Law And Executive Order," which is attached to this application and agree to comply with the requirements in this Notice.

If Applicant is a proprietor or partnership, sign below.

By:

I f Applicant is a Corporation, sign below:

Corporate Name and Seal Date

By:

Signature of President

Attested by:

Signature of Corporate Secretary

APPLICANT’S CERTIFICATIONS

READ THE FOLLOWING CAREFULLY -- FALSE STATEMENTS ARE SUBJECT TO CRIMINAL PROSECUTION:

If you knowingly make a false statement, you can be fined up to $250,000 and/or imprisoned for not more than five years under 18 USC 1001; if submitted to a Federally insured institution, under 18 USC 1014 by Imprisonment of not more than twenty years and/or a fine of not more than $1,000,000

By signing below you certify as to the following:

(a) You have reviewed (1) the responses to the question about debt on page 1 of the application; (2) the responses to questions 11, 12, and 13 (application-page 3), and (3) any financial statement that you were required to complete as Exhibit B or F to the application and certify that as to you personally all information in this Application and Financial Statement is true and complete to the best of your knowledge. You acknowledge that this information is being submitted to a lender and SBA so they can decide to make a loan or give a loan guaranty, and that the lender and SBA are relying on this information.

(b) You have read a copy of the "Statements Required By Law And Executive Order," which is attached to this application and agree to comply with the requirements in this Notice.

Business Name:

Other than the person that signed on page 3, each Partner, each Stockholder owning 20% or more, and each Guarantor must sign below. In addition, if a husband and wife collectively own 20% or more of a company, each spouse must also sign. No one should sign more than once.

_____________________________________________________

Signature Date

Check all that apply: [ ] guarantor [ ] owner-indicate percentage owned: [ ] [ ] partner-indicate whether [ ] general or [ ] limited

Signature Date

Check all that apply: [ ] guarantor [ ] owner-indicate percentage owned: [ ] [ ] partner-indicate whether [ ] general or [ ] limited

Signature Date

Check all that apply: [ ] guarantor [ ] owner-indicate percentage owned: [ ] [ ] partner-indicate whether [ ] general or [ ] limited

Signature Date

Check all that apply: [ ] guarantor [ ] owner-indicate percentage owned: [ ] [ ] partner-indicate whether [ ] general or [ ] limited

Signature Date

Check all that apply: [ ] guarantor [ ] owner-indicate percentage owned: [ ] [ ] partner-indicate whether [ ] general or [ ] limited

Signature Date

Check all that apply: [ ] guarantor [ ] owner-indicate percentage owned: [ ] [ ] partner-indicate whether [ ] general or [ ] limited

Signature Date

Check all that apply: [ ] guarantor [ ] owner-indicate percentage owned: [ ] [ ] partner-indicate whether [ ] general or [ ] limited

PLEASE READ, DETACH, AND RETAIN FOR YOUR RECORDS

STATEMENTS REQUIRED BY LAW AND EXECUTIVE ORDER

Federal executive agencies, including the Small Business Administration (SBA), are required to withhold or limit financial assistance, to impose special conditions on approved loans, to provide special notices to applicants or borrowers and to require special reports and data from borrowers in order to comply with legislation passed by the Congress and Executive Orders issued by the President and by the provisions of various inter-agency agreements. SBA has issued regulations and procedures that implement these laws and executive orders, and they are contained in Parts 112, 113, 116, and 117, Title 13, Code of Federal Regulations Chapter 1, or Standard Operating Procedures.

Freedom of Information Act (5 U.S.C. 552)

This law provides, with some exceptions, that 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.

Privacy Act (5 U.S.C. 552a)

A person can request to see or get copies of any personal information that SBA has in his or her file when that file is retrievable by individual identifiers such as name or social security numbers. 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.

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. Disclosures of name and other personal identifiers are, however, required for a benefit, as SBA requires an individual seeking assistance from SBA to provide it with sufficient information for it to make a character determination. In determining whether an individual is of good character, SBA considers the person’s integrity, candor, and disposition toward criminal actions. In making loans pursuant to section 7(a)(6) of the Small Business Act (the Act), 15 USC Section 636(a)(6), SBA is required to have reasonable assurance that the loan is of sound value and will be repaid or that it is in the best interest of the Government to grant the assistance requested. 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). Further, for all forms of assistance, SBA is authorized to make all investigations necessary to ensure that a person has not engaged in acts that violate or will violate the Act or the Small Business Investment Act, 15 USC Sections 634(b)(11) and 687(b)(a). For these purposes, you are asked to voluntarily provide your social security number to assist SBA in making a character determination and to distinguish you from other individuals with the same or similar name or other personal identifier.

The Privacy Act authorizes SBA to make certain “routine uses” of information protected by that Act. One such routine use for SBA’s loan system of records is that when this information indicates a violation or potential violation of law, whether civil, criminal, or administrative in nature, SBA may refer it 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 of personal information is to assist in obtaining credit bureau reports, including business credit reports on the small business borrower and consumer credit reports and scores on the principals of the small business and guarantors on the loan for purposes of originating, servicing, and liquidating small business loans and for purposes of routine periodic loan portfolio management and lender monitoring. See, 69 F.R. 58598, 58617 (and as amended from time to time) for additional background and other routine uses.

Right to Financial Privacy Act of 1978 (12 U.S.C. 3401)

This is notice to you as required by the Right of Financial Privacy Act of 1978, of SBA's access rights to financial records held by financial institutions that are or have been doing business with you or your business, including any financial institutions participating in a loan or loan guarantee. The law provides that SBA shall have a right of access to your financial records in connection with its consideration or administration of assistance to you in the form of a Government loan or loan guaranty agreement. SBA is required to 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, after which no further certification is required for subsequent accesses. The law also provides that SBA's access rights continue for the term of any approved loan or loan guaranty agreement. No further notice to you of SBA's access rights is required during the term of any such agreement.

The law also authorizes SBA to transfer to another Government authority any financial records included in an application for a loan, or concerning an approved loan or loan guarantee, as necessary to process, service or foreclose on a loan or loan guarantee or to collect on a defaulted loan or loan guarantee. No other transfer of your financial records to another Government authority will be permitted by SBA except as required or permitted by law.

Flood Disaster Protection Act (42 U.S.C. 4011)

Regulations have been issued by the Federal Insurance Administration (FIA) and by SBA implementing this Act and its amendments. These regulations prohibit SBA from making certain loans in an FIA designated floodplain unless Federal flood insurance is purchased as a condition of the loan. Failure to maintain the required level of flood insurance makes the applicant ineligible for any future financial assistance from SBA under any program, including disaster assistance.

Executive Orders -- Floodplain Management and Wetland Protection (42 F.R. 26951 and 42 F.R. 26961)

The SBA discourages any settlement in or development of a floodplain or a wetland. This statement is to notify all SBA loan applicants that such actions are hazardous to both life and property and should be avoided. The additional cost of flood preventive construction must be considered in addition to the possible loss of all assets and investments in future floods.

Occupational Safety and Health Act (15 U.S.C. 651 et seq.)

This legislation authorizes the Occupational Safety and Health Administration in the Department of Labor to require businesses to modify facilities and procedures to protect employees or pay penalty fees. In some instances the business can be forced to cease operations or be prevented from starting operations in a new facility. Therefore, in some instances SBA may require additional information from an applicant to determine whether the business will be in compliance with OSHA regulations and allowed to operate its facility after the loan is approved and disbursed. Signing this form as borrower is a certification that the OSA requirements that apply to the borrower's business have been determined and the borrower to the best of its knowledge is in compliance.

Civil Rights Legislation

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. This includes making their goods and services available to handicapped clients or customers. All business borrowers will be required to display the "Equal Employment Opportunity Poster" prescribed by SBA.

Equal Credit Opportunity Act (15 U.S.C. 1691)

The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status or age (provided that 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. The Federal agency that administers compliance with this law concerning this creditor is the Federal Trade Commission, Equal Credit Opportunity, Washington, D.C. 20580.

Executive Order 11738 -- Environmental Protection (38 C.F.R. 25161)

The Executive Order charges SBA with administering its loan programs in a manner that will result in effective enforcement of the Clean Air Act, the Federal Water Pollution Act and other environmental protection legislation. SBA must, therefore, impose conditions on some loans. By acknowledging receipt of this form and presenting the application, the principals of all small businesses borrowing $100,000 or more in direct funds stipulate to the following:

1. That any facility used, or to be used, by the subject firm is not cited on the EPA list of Violating Facilities.

2. That subject firm will comply with all the requirements of Section 114 of the Clean Air Act (42 U.S.C. 7414) and Section 308 of the Water Act (33 U.S.C 1318) relating to inspection, monitoring, entry, reports and information, as well as all other requirements specified in Section 114 and Section 308 of the respective Acts, and all regulations and guidelines issued hereunder.

3. That subject firm will notify SBA of the receipt of any communication from the Director of the Environmental Protection Agency indicating that a facility utilized, or to be utilized, by subject firm is under consideration to be listed on the EPA List of Violating Facilities.

Debt Collection Act of 1982 Deficit Reduction Act of 1984 (31 U.S.C. 3701 et seq. and other titles)

These laws require SBA to aggressively collect any loan payments which become delinquent. 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 take one or more of the following actions:

- Report the status of your loan(s) to credit bureaus

- Hire a collection agency to collect your loan

- Offset your income tax refund or other amounts due to you from the Federal Government

- Suspend or debar you or your company from doing business with the Federal Government

- Refer your loan to the Department of Justice or other attorneys for litigation

- Foreclose on collateral or take other action permitted in the loan instruments.

Immigration Reform and Control Act of 1986 (Pub. L. 99-603)

If you are an alien who was in this country illegally since before January 1, 1982, you may have been granted lawful temporary resident status by the United States Immigration and Naturalization Service pursuant to the Immigration Reform and Control Act of 1986 (Pub. L. 99-603). For five years from the date you are granted such status, you are not eligible for financial assistance from the SBA in the form of a loan or guaranty under section 7(a) of the Small Business Act unless you are disabled or a Cuban or Haitian entrant. When you sign this document, you are making the certification that the Immigration Reform and Control Act of 1986 does not apply to you, or if it does apply, more than five years have elapsed since you have been granted lawful temporary resident status pursuant to such 1986 legislation.

Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4821 et seq.)

Borrowers using SBA funds for the construction or rehabilitation of a residential structure are prohibited from using lead-based paint (as defined in SBA regulations) on all interior surfaces, whether accessible or not, and exterior surfaces, such as stairs, decks, porches, railings, windows and doors, which are readily accessible to children under 7 years of age. A "residential structure" is any home, apartment, hotel, motel, orphanage, boarding school, dormitory, day care center, extended care facility, college or other school housing, hospital, group practice or community facility and all other residential or institutional structures where persons reside.

Executive Order 12549, Debarment and Suspension (13 C.F.R. 145)

1. The prospective lower tier participant certifies, by submission of this loan application, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

2. Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participants shall attach an explanation to the loan application.

SBA Form 4 (9-09) Previous Edition Obsolete Page 8