Sba Form 1993 – Fill Out and Use This PDF

Instructions

1.Complete, sign and date this form. (Signature not required if completed at www.sba.gov/ombudsman).

2.Provide a brief written statement on the reverse side regarding the specific enforcement or compliance action taken against your organization by the federal agency.

3.Submit copies of substantiating documentation, such as correspondence, citation, or notice (Note: Can be submitted separately from this form by fax or mail. Make sure to reference your name or company's name with this information).

4.If your comments concern the IRS, you must also submit a completed IRS Tax Information Authorization Form 8821, available at http://www.irs.gov/forms (Can be sent by fax or mail).

5.Fax, e-mail or send this form and requested information to: (1) Fax: (202) 481-5719; (2) E-mail: Ombudsman@sba.gov; (3) Address: SBA,

Office of the National Ombudsman, 409 Third Street, SW, Washington, DC 20024. Telephone : (202) 205-2417.

Please Print

Organization/Company Name :

Address:

City :__________________________________________ State :__________________________ Zip :_____________________

Please indicate your organization type:

Small BusinessNot-for-Profit, Representing ________________________ Members

Small Government (population of less than 50,000)

List the federal agency with which you are having a problem:

Federal Agency Name:

Agency Contact person:

Agency Office/Division:

Did the federal agency listed above inform you of your right to contact the SBA Office of the National Ombudsman?

?	Yes	?	No	If not, how did you learn about this office?

_______________________________________________________________________________________________

Confidentiality / Disclosure

The Small Business Regulatory Enforcement Fairness Act (SBREFA), allows you to keep your identity and other information private, and limit its access only to the SBA's (See 15 U.S.C. 657 (b) (2) (B)). However, by requesting confidentiality the federal agency may not have sufficient information to investigate your specific problem, possibly delaying or preventing any potential resolution of your situation.

Signature :	Date :

Your signature authorizes the SBA Ombudsman to proceed on your behalf.

Pursue all legal options you believe are in your company’s best interest.

This process is not a substitute for legal action.

SBA FORM 1993 (3-10) Previous Editions Obsolete

Please Note: The estimated burden for completing this form is 45 minutes. You will not be required to respond to this information collection if a valid OMB the U. S. Small Business Administration, Chief, Administrative Information Branch, Washington, D.C . 20416 and/or Office of Management and Budget,

Clearance approval number is not displayed. If you have any questions or comments concerning this estimate or other aspects of this information collection,

.

please contact Officer, Paperwork Reduction Project (3245-0313), Washington, D.C. 20503 PLEASE DO NOT SEND FORMS TO OMB.