Sba Form 1919 Fillable – Fill Out and Use This PDF

Purpose of this form:

The purpose of this form is to collect information about the Small Business Applicant ("Applicant") and its owners, the loan request, existing indebtedness, information about current or previous government financing, and certain other topics. The information also facilitates background checks as authorized by section 7(a)(1)(B) of the Small Business Act, 15 U.S.C. 636(a)(1)(B). Submission of the requested information is required for SBA or the Lender to determine eligibility for financial assistance. Failure to submit the information would affect that determination.

Instructions for completing this form: This form is to be completed by the Applicant and all individuals identified

below and submitted to an SBA Participating Lender. This form is divided into three sections: Section I requests

information about the Small Business Applicant and must be completed in its entirety, signed and dated by an authorized representative of the Small Business Applicant that is requesting a business loan. A separate Section I is required to be

completed and signed for each co-applicant (e.g. "Eligible Passive Company (EPC)" or "Operating Company (OC)").

Sections II and III of this form requests information about each of the Applicant's owners - Section II for individuals, Section

IIIfor each entity owning an equity interest in the Applicant (e.g. Employee Stock Ownership Plan ("ESOP"), 401(k) plan, Limited Liability Company, or other entity owner entities and trusts. A separate Section II and/or Section III is required to be completed and signed by:

O For a sole proprietorship, the sole proprietor;

OFor a partnership, all general partners, and all limited partners owning 20% or more of the equity of the firm; or any partner that is involved in management of the applicant business;

OFor a corporation, all owners of 20% or more of the corporation, and each officer and director;

OFor limited liability companies, all members owning 20% or more of the company, each officer, director,

and managing member;

OAny person hired by the Applicant to manage day-to-day operations of the Applicant business ("key employee"); and

OAny Trustor (if the Applicant is owned by a trust).

OEach entity owning an equity interest in the Applicant.

All parties listed above are considered "Associates" of the Small Business Applicant as defined in 13 CFR § 120.10. A separate Section I (for the Applicant and each Co-Applicant), Section II (for individuals), and Section III (for entities) is required to be completed and signed by each Associate of the Small Business Applicant.

Definitions:

1.Affiliation - Concerns and entities are affiliates of each other when one controls or has the power to control the other, or a third party (or parties) controls or has power to control both. For example, affiliation may arise through ownership, common management (including through a management agreement), or when there is an identity of interest between close relatives with identical, or substantially identical, business interests. The complete definition of "affiliation" is found at 13 CFR § 121.301(f).

2.Close Relative - Close Relative is a spouse; a parent; or a child or sibling, or the spouse of any such person.

3.Eligible Passive Company ("EPC") - is a small entity or trust which does not engage in regular and continuous business activity which leases real or personal property to an Operating Company for use in the Operating Company's business, and which complies with the conditions set forth in 13 CFR § 120.111.

4.Household Member - A "household member" of an SBA employee includes: a) the spouse of the SBA employee; b) the minor children of said individual; and c) the blood relatives of the employee, and the blood relatives of the employee's spouse who reside in the same place of abode as the employee. [13 CFR § 105.201(d)]

5.Operating Company ("OC") - is an eligible small business actively involved in conducting business operations now or about to be located on real property owned by an Eligible Passive Company, or using or about to use in its business operations personal property owned by an Eligible Passive Company.

For clarification regarding any of the questions or terms contained herein, please contact your Lender.

SBA Form 1919 (Revised 09/20)

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Applicant Business Legal Name (OC

EPC

):

Operating Business Legal Name (OC):

DBA or Trade name, if applicable:

Is the Applicant a?: Cooperative:

ESOP:

401(k) Plan:

Trust:

Other:

N/A:

Yes

No

Do you plan to use a 401(K) Plan (including a Rollover for Business Start Up (ROBS) Plan) for equity?

Will a Management Company be hired by the Applicant to manage the day-to-day operations?

Yes

No

(If yes, provide a copy of the management agreement)

Primary Business Address

Business Tax ID

Primary Business Phone

			# of existing employees employed by business?
$			(including owners):
			# of jobs to be created as a result of the loan? (including
			owners):

#of jobs that will be retained as a result of the loan that otherwise would have been lost? (including owners):

If financial statements provided to the lender do not include a schedule of business debt, provide on a separate attachment.

Ownership of the Applicant

List all proprietors, partners, officers, directors, members, and holders of outstanding stock. 100% of ownership must be reflected. Attach a separate sheet if necessary. Based on the instructions to this form not all owners will need to complete the Associate's Information section of this form.

If any owner(s) is an ESOP, a 401(k) plan, or a Cooperative, please provide details and relevant documentation to the Lender as appropriate.

*Any Applicant owned in part, or in whole, by an ESOP or 401(k) plan must also provide to the Lender evidence that the Applicant, ESOP or the 401(k) plan are in compliance with all applicable IRS, Treasury, and Department of Labor requirements and it will comply with all relevant operating and reporting requirements.

SBA Form 1919 (Revised 09/20)

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Unless stated otherwise, if any of the questions below are answered "Yes," please provide details on a separate sheet.

	#	Question			Yes			No
	1	Are there co-applicants? (If "Yes," please complete a separate Section I: Applicant Business
		Information for each.)
	2	Has an application for the requested loan ever been submitted to the SBA, a lender, or a Certified
		Development Company, in connection with any SBA program?
		Has the Applicant and/or its Affiliates ever obtained or applied for a direct or guaranteed loan from
	3	SBA, or another Federal agency loan program (including, but not limited to USDA, B&I, FSA, EDA),
		or been a guarantor on such a loan? (if "Yes," answer questions 3.a) and 3.b) below.)
	3	a) Is any of the financing currently delinquent?
	3	b) Did any of this financing ever default and cause a loss to the Federal Government?
	4	Is the Applicant presently suspended, debarred, proposed for debarment, declared ineligible, or
		voluntarily excluded from participation in this transaction by any Federal department or agency?
		Does the Applicant Business operate under a Franchise/License/Distributor/Membership/Dealer/
	5	Jobber or other type of Agreement? (If "Yes," provide copies of your agreement(s) and any other
		relevant documents.)
	6	Does the Applicant have any Affiliates per 13 CFR 121.301? (If "Yes", attach a listing of all
		Affiliates.)
	7	Has the Applicant and/or its Affiliates ever filed for bankruptcy protection?
	8	Is the Applicant and/or its Affiliates presently involved in any pending legal action?
		Are any of the Applicant's products and/or services exported (directly or indirectly), is there a plan to
	9	begin exporting (directly or indirectly) as a result of this loan, or is this an Export Working Capital
		Program (EWCP)* loan? (If "Yes," answer questions 9.a) and 9.b) below.)
		a) Provide the estimated total export sales this loan will support.		$
	9	* (For EWCP loans, in a separate attachment, provide details of the underlying transaction(s) for which the loan
		is needed, countries where the buyers are located and a description of products and/or services to be exported.)

9b) List of principal countries of export (list at least 1)

	Has the Applicant paid or committed to pay a fee to the Lender or a third party to assist in the
10	preparation of the loan application or application materials, or has the Applicant paid or committed to
	pay a referral agent or broker a fee?
	Are any of the Applicant's revenues derived from gambling, loan packaging, or from the sale of
11	products or services, or the presentation of any depiction, displays or live performances, of a prurient
	sexual nature? If "Yes," provide details under a separate attachment.

SBA Form 1919 (Revised 09/20)

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SBA may not provide financial assistance to an applicant where there is any appearance of a conflict of interest with an SBA or other Federal government employee. If any of the questions below are answered "Yes," please provide details on a separate sheet.

With the exception of question 15, if any of the questions below are answered "Yes," this application may not be submitted under any delegated processing method, but must be submitted by the Lender under non-delegated processing. Note: This does not mean that your loan will be denied, only that your Lender will need to use different SBA procedures to process this loan. If the answer to question 15 is "Yes," the application may be processed under a lender's delegated authority only after the lender receives clearance to do so from SBA.

#	Question	Yes	No

Is any sole proprietor, partner, officer, director, stockholder with a 10 percent or more interest in the

12Applicant an SBA employee or a Household Member of an SBA employee? (13 CFR 105.204). "Household Member" means spouse and minor children of an employee, all blood relations of the employee and any spouse who resides in the same place of abode with the employee (13 CFR §105.201(d)).

	Is any employee, owner, partner, attorney, agent, owner of stock, officer, director, creditor or debtor of the
13	Applicant a former SBA employee who has been separated from SBA for less than one year prior to the
	request for financial assistance? (13 CFR 105.203)
	Is any sole proprietor, general partner, officer, director, or stockholder with a 10 percent or more interest in
14	the Applicant, or a household member of such individual, a member of Congress, or an appointed official or
	employee of the legislative or judicial branch of the Federal Government? (13 CFR 105.301(c))
	Is any sole proprietor, general partner, officer, director, or stockholder with a 10 percent or more interest in
15	the Applicant, or a household member of such individual, a Federal Government employee or Member of the
	Military having a grade of at least GS-13 or higher (or Military equivalent)? (13 CFR 105.301(a))
	Is any sole proprietor, general partner, officer, director, or stockholder with a 10 percent or more interest in
16	the Applicant, or a household member of such individual, a member or employee of a Small Business
	Advisory Council or a SCORE volunteer? (13 CFR 105.302(a))

SBA Form 1919 (Revised 09/20)

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By Signing Below, You Make the Following Representations, Acknowledgement, and Certification

REPRESENTATIONS

I represent that:

•I have read the Statements Required by Law and Executive Order included in this form, and I understand them.

•I will comply, whenever applicable, with the hazard insurance, lead-based paint, 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.

•The Applicant is not knowingly engaged and will not knowingly engage in any activity that is illegal under federal, state, or local law or that can reasonably be determined to support or facilitate any activity that is illegal under federal, state, or local law.

•I understand, acknowledge, agree, and consent that the Lender can use and share any tax information that I have provided and/or that the Lender has obtained from the Internal Revenue Service with SBA's authorized representatives, including authorized representatives of the SBA Office of Inspector General, for the purpose of compliance with SBA Loan Program Requirements and all SBA reviews.

ACKNOWLEDGEMENT

I acknowledge that:

•SBA encourages the purchase, to the extent feasible, of American-made equipment and supplies.

ACCURACY CERTIFICATION

I certify that the information provided in this application and the information that I have provided in all supporting documents and forms is true and accurate. I realize that the penalty for knowingly making a false statement to obtain a guaranteed loan from SBA is that I may be fined up to $250,000 and/or be put in jail for up to 5 years under 18 USC § 1001; under 15 USC 645 by imprisonment of not more than two years and/or a fine of not more than $5,000; and, if false statements are submitted to a Federally insured institution, I may be fined up to $1,000,000 and/or be put in jail for up to 30 years under 18 USC § 1014.

Signature of Authorized Representative of Applicant		Date:
		Title
Print Name

SBA Form 1919 (Revised 09/20)

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