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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Individual Owner's Full Legal Name		Social Security / Tax ID	Date of Birth	Place of Birth (City, State,
		No.		Country)
Home Address			Home Phone	% of Ownership
Applicant Legal Name:

Veteran/Gender/Race/Ethnicity data is collected for program reporting purposes only.

	Disclosure is voluntary and has no bearing on the credit decision.
		Enter Response
Veteran	1=Non-Veteran; 2=Veteran; 3=Service-Disabled Veteran; 4=Spouse of Veteran; X=Not
Gender	M=Male; F=Female; X=Not Disclosed
Race (more	1=American Indian or Alaska Native; 2=Asian; 3=Black or African-American; 4=Native
than 1 may be)	Hawaiian or Pacific Islander; 5=White; X=Not Disclosed
Ethnicity	H=Hispanic or Latino; N=Not Hispanic or Latino; X=Not Disclosed

	Question		Yes			No
	Are you presently subject to an indictment, criminal information, arraignment, or other means by
17	which formal criminal charges are brought in any jurisdiction? (If "YES," the loan request is not
	eligible for SBA assistance.)
Initial here to confirm your response to question 17 (originally initialed, or an acceptable electronic
signature, and not typed.) è
18	Have you been arrested in the last 6 months for any criminal offense?
Initial here to confirm your response to question 18 (originally initialed, or an acceptable electronic
signature, and not typed.) è
	For any criminal offense - other than a minor vehicle violation	- have you ever: 1) been convicted; 2)
19	pleaded guilty; 3) pleaded nolo contendere; 4) been placed on pretrial diversion; or 5) been placed on
	any form of parole or probation (including probation before judgment)?

Initial here to confirm your response to question 19 (originally initialed, or an acceptable electronic signature, and not typed.) è

If you answer "Yes" to questions 18 or 19, you must furnish details, including dates, location, fines, sentences, level of charge (whether misdemeanor or felony), dates of parole/probation, unpaid fines or penalties, name(s) under which charged, and any other pertinent information. If you answer "Yes" to question 19 and are currently on parole or probation, the loan request is not eligible for SBA assistance.

Initial here to confirm your response to question 20 (originally initialed, or an acceptable electronic signature, and not typed.) è

*Businesses with ownership that includes Foreign Nationals or Foreign Entities may be eligible only if the business is at least 51% owned and controlled by U.S. citizens and/or those who have LPR status from USCIS whose status will be verified by the Lender in accordance with SBA Loan Program Requirements.

SBA Form 1919 (Revised 09/20)

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	Question	Yes			No
	Are you presently suspended, debarred, proposed for debarment, declared ineligible, or voluntarily
21	excluded from participation in this transaction by any Federal department or agency?	(If "Yes," the
	application is not eligible for SBA financial assistance)
	If you are a 50% or more owner of the Applicant, are you more than 60 days delinquent on any
	obligation to pay child support arising under an administrative order, court order, repayment
22	agreement between the holder and a custodial parent, or repayment agreement between the holder and
	a state agency providing child support enforcement services. (If "Yes," the application is not eligible
	for SBA financial assistance)
	Do you have any ownership in other businesses which would be defined as an Affiliate of the
23	Applicant in the definition found on page 1? (If "Yes," attach a listing of all businesses, your title and
	ownership percentage in the business.)
24	Have you, or any business you controlled, ever filed for bankruptcy protection? If yes, provide details.

25Are you, or any business you control, presently involved in any legal action (including divorce)? If yes, provide details.

	Have you or any business owned or controlled by you ever obtained a direct or guaranteed loan from
26	SBA or any other Federal agency or been a guarantor on such a loan? (This includes, but is not
	limited to USDA, FHA, EDA, and student loans.)
26	(a) If you answered "Yes" to Question 26, is any of the financing presently considered delinquent?

(b)If you answered "Yes" to Question 26, did any loan that was made for business purposes ever default and cause a loss to the Government, including a compromise, resolution or settlement of a

26loan's principal balance for less than the full amount due? (If you answer "Yes" to either 26(a) or 26(b) above, please provide Lender with a written explanation.)

SBA Form 1919 (Revised 09/20)

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

REPRESENTATIONS, ACKNOWLEDGEMENT AND AUTHORIZATION

I represent that:

•I have read the Statements Required by Law and Executive Order and I understand them.

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

I acknowledge that:

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

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.

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

Date:

Print Name and Title

SBA Form 1919 (Revised 09/20)

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Applicant Legal Name:

Entity Owner Legal Name

Tax ID

Phone

Identify in what capacity you are Completing this Section? Check all that apply.

401(k) Plan ESOP Other (Explain in separate attachment):

Entity Ownership

List all proprietors, partners, officers, directors, members, Trustees, and holders of outstanding stock in the entity owner. 100% of ownership must be disclosed. Attach a separate sheet if necessary.

If any of the questions below are answered "Yes," please provide details on a separate sheet.

#	Question	Yes			No
	Is the Entity, or any of its owners, presently suspended, debarred, proposed for debarment, declared
27	ineligible, or voluntarily excluded from participation in this transaction by any Federal department or
	agency? (If "Yes," the application is not eligible for SBA financial assistance).
28	Does the entity have any Affiliates? (If "Yes," attach a listing of all Affiliates.)
29	Has the entity and/or its Affiliates ever filed for bankruptcy protection?
30	Is the entity and/or its Affiliates presently involved in any pending legal action?
31	Has the Entity ever obtained a direct or guaranteed loan from SBA or any other Federal agency or been a
	guarantor on such a loan? (This includes, but is not limited to USDA, FHA, EDA.)
31	(a) If you answered "Yes" to Question 31, is any of the financing presently considered delinquent?

(b)If you answered "Yes" to Question 31, did any loan that was for a business purpose ever default and cause a loss to the Government, including a compromise, resolution or settlement of a loan's principal

31balance for less than the full amount due?

(If you answer "Yes" to either 31(a) or 31(b) above, please provide Lender with a written explanation)

SBA Form 1919 (Revised 09/20)

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

REPRESENTATIONS, ACKNOWLEDGEMENT AND AUTHORIZATION

I represent that:

•I have read the Statements Required by Law and Executive Order and I understand them.

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

I acknowledge that:

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

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.

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 Entity

Date:

Print Name and Title

SBA Form 1919 (Revised 09/20)

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Please read the following notices regarding use of federal financial assistance programs and then sign and date the certification.

This application and any assistance provided pursuant to this application is subject to the following laws, regulations, and Executive Orders.

Privacy Act (5 U.S.C. 552a); Collection of Social Security Number (31 U.S.C.7701)

Authorities and Purpose for Collecting Information: SBA is collecting the information on this form, including social security numbers and other personal information, to make a character and credit eligibility decision in connection with you or your company's application for SBA assistance. SBA may also use social security numbers for the purpose of collecting and reporting on any delinquent fees or other amounts owed SBA. Under the provisions of 31 U.S.C. 7701, the applicant business and any guarantor of the loan are required to provide their social security numbers or other taxpayer identification numbers in order to do business with SBA. Failure to provide this information would affect your ability to obtain a 7(a) loan. For other individuals signing this application, the submission of the social security number is voluntary and failure to provide your social security number may not affect any right, benefit or privilege to which you are entitled.

In evaluating whether the applicant satisfies the criteria for a 7(a) loan, SBA considers whether the applicant and each of its Associates possess good character. In making this determination, SBA considers the person's integrity, candor, and criminal history if any. SBA is specifically authorized to verify your criminal history, or lack thereof, pursuant to section 7(a)(1)(B), of the Small Business Act, 15 USC Section 636(a)(1)(B). In addition, 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 Small Business Act, 15 U.S.C. 634(b)(11). In conducting the criminal background check, SBA also uses your social security number to distinguish you from other individuals with the same or similar name or other personal identifiers. This use is permitted under Executive Order 9397.

Routine Uses: Some of the information collected may be checked against criminal history indices of the Federal Bureau of Investigation. When the information collected 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. See SBA's Privacy Act System of Records, at 74 Fed. Reg. 14890 (2009) (as amended from time to time) for other published r

Right to Financial Privacy Act of 1978 (12 U.S.C. 3401) -- As required by this statute, SBA provides this notice of its right to access your financial records held by financial institutions, including any institution participating in a loan or loan guarantee, that are or have been doing business with you or your business. 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 access. 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.

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 is generally 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 the amount of the loan, and the type of loan. 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.

SBA Form 1919 (Revised 09/20)

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Debt Collection Act of 1982 (5 U.S.C. 5514 note) and Debt Collection Improvement Act of 1996 (31 U.S.C. 3701 et seq.) -- These laws require SBA to aggressively collect any loan or other payments that 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: (1) report the status of your loan(s) or other debt owed to SBA to credit bureaus, (2) hire a collection agency to collect your loan or other delinquent debt, (3) offset your income tax refund 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 other attorneys for litigation, or (6) foreclose on collateral or take other action permitted in the loan instruments. Finally, if you default on an SBA loan and fail to fully reimburse the Agency for any resulting loss, SBA may

refer you to the computer database of delinquent Federal debtors maintained by the Department of Housing and Urban Development or another Federal agency. This referral may result in your being disqualified from receiving financial assistance from other Federal agencies. In addition, unless SBA is reimbursed in full for the loss, you will not eligible for additional SBA financial assistance.

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 financial assistance from SBA, including disaster assistance.

Executive Orders -- Floodplain Management and Wetland Protection (42 F.R. 26951 and 42 F.R. 26961) -- SBA discourages 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 due to a future flood.

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 and required to abate the hazards in their workplaces. They may also be ordered to cease operations posing an imminent danger of death or serious injury until employees can be protected. Signing this 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 Legislation (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. 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 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.

Executive Order 11738 -- Environmental Protection (38 F.R. 251621) -- 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 environment protection legislation.

SBA Form 1919 (Revised 09/20)

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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 (2 CFR 180, adopted by reference in 2 CFR Part 2700 (SBA Debarment Regulations))

--By submission of this loan application, you certify and acknowledge that neither you nor any Associates have within the past three years been: (a) debarred, suspended, declared ineligible from participating in, or voluntarily excluded from participation in a transaction by any Federal department or 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 due and owing to the U.S. Government or its agencies or instrumentalities as of the date of execution of this certification.

If you are unable to certify and acknowledge (a) through (d), you must obtain and attach a written statement of exception from SBA permitting participation in this loan. You further certify that you have not and will not knowingly enter into any agreement in connection with the goods and/or services purchased with the proceeds of this loan with any individual or entity that has been debarred, suspended, declared ineligible from participating in, or voluntarily excluded from participation in a Transaction. All capitalized terms have the meanings set forth in 2 C.F.R. Part 180.

NOTE: According to the 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 burden for completing this form, including time for reviewing instructions, gathering data needed, and completing and reviewing the form is 15 minutes per response. Comments or questions on the burden estimates should be sent to U.S. 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, Rm. 10202, Washington DC 20503.

PLEASE DO NOT SEND FORMS TO THESE ADDRESSES.

SBA Form 1919 (Revised 09/20)

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