Sba Form 5 – Fill Out and Use

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U.S. Small Business Administration

OMBNo. : 3245-0017

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DISASTER BUSINESS LOAN APPLICATION

Expiration: 08/31/2021

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FOR SBA INTERNALUSE ONLY

Date Received

Location

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Physical Declaration Number

Filing Deadline Date

Economic Injury Declaration Number

Filing Deadline Date

FEMA Registration Number

SBA Application Number

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(if known)

1.ARE YOU APPLYING FOR:

•	Physical Damage -- Indicate type of damage		• Military Reservist EIDL (MREIDL)
	• Real Property	• Business Contents	(complete the following)
•			* Name of Essential Employee
	Economic Injury (EIDL)		* Employee'sSocialSecurityNumber

PLEASE PROVIDE ALL INFORMATION OR DOCUMENTATION REQUESTED IN THE ATTACHED FILING REQUIREMENTS.

* For information about these questions, see the attached Statements Required by Laws and Executive Orders.

Apply online at https://disasterloan.sba.gov/ela/ OR send completed applications to:

U.S. Small Business Administration, Processing and Disbursement Center, 14925 Kingsport Road, Fort Worth, Texas 76155

2.ORGANIZATION TYPE *Sole Proprietors should complete form 5C

•	Partnership	• Limited Partnership		•	Limited Liability Entity
•	Corporation	•	Nonprofit Organization	•	Trust	• Other:
3. APPLICANT'S LEGAL NAME					4. FEDERAL E.I.N. (if applicable)

7. MAILING ADDRESS	•	Business	•	Home	•	Temp	•	Other

Number, Street, and/or Post Office Box	I		I	I		I
	City		County	State		Zip
8. DAMAGED PROPERTY ADDRESS(ES)				BUSINESS PROPERTY IS:
(If you need more space, attach additional sheets.)		•	Same as mailing address	•	Owned		• Leased
Number and Street Name	City		County	State		Zip
	I		I	I		I

9.PROVIDE THE NAME(S) OF THE INDIVIDUAL(S) TO CONTACT FOR:

	Loss Verification Inspection							Information necessary to process the Application
Name					Name
Telephone Number					Telephone Number
10. ALTERNATE WAY TO CONTACT YOU
•	Cell Number				•	E-mail
•	Fax Number				•	Other
11.	BUSINESS ACTIVITY:					12. NUMBER OF EMPLOYEES (pre-disaster):
13.	DATE BUSINESS ESTABLISHED:					14. CURRENT MANAGEMENT SINCE:
15.	AMOUNT OF ESTIMATED LOSS:		•	Real Estate	B				• Inventory	B
	If unknown, enter a question mark							•
	•	Machinery & Equipment							Leasehold Improvements
16.	INSURANCE COVERAGE (IF ANY)			I Coverage Type:
	(If you need more space, attach additional sheets.)
Name of Insurance Company and Agent
Phone Number of Insurance Agent							IPolicy Number
SBA Form 5 (05-18) Ref SOP 50 30

Page 1 of 6

17. OWNERS	(Individuals and businesses.)		Complete for each: 1) proprietor, or 2) limited partner who owns 20% or more interest and each
	(If you need more space attach additional sheets.)		general partner, or 3) stockholder or entity owning 20% or more voting stock.
Legal Name					Title/Office		% Owned	IE-mail Address
SSN/EIN*	Marital Status	Date of Birth*	Place of Birth*				Telephone Number (area code)			US Citizen
	I	I	I							• Yes •	No
Mailing Address					City				IState	Zip
Legal Name					Title/Office		% Owned	IE-mail	Address
SSN/EIN*	Marital Status	Date of Birth*	Place of Birth*				Telephone	Number (area code)		US Citizen
	I	I	I							• Yes •	No
Mailing Address					City				IState	Zip
* For information about these questions, see the attached Statements Required by Laws and Executive Orders.
Business Entity Owner				EIN			Type of Business			% Ownership
Name
Mailing Address				City				IState	lZip Code
E-mail Address						IPhone

18. For the applicant business and each owner listed in item 17, please respond to the following questions, providing dates and details on any question answered YES (Attach an additional sheet for detailed responses).

a)are you presently subject to an indictment, criminal information, arraignment, or other means by which formal criminal charges are brought in any jurisdiction; b) have you been arrested in the past six months for any criminal offense; c) for any criminal offense - other than a minor vehicle violation - have you ever: 1) been convicted, 2) plead guilty, 3) plead nolo contendere, 4) been placed on pretrial diversion, or 5) been placed on

any form of parole or probation (including probation before judgement)?
• Yes • No	If yes, Name:

20.PHYSICAL DAMAGE LOANS ONLY. If your application is approved, you may be eligible for additional funds to cover the cost of mitigating measures (real property improvements or devices to minimize or protect against future damage from the same type of disaster event).

It is not necessary for you to submit the description and cost estimates with the application. SBA must approve the mitigating measures •before any loan increase.By checking this box, I am interested in having SBA consider this increase.

21.If anyone assisted you in completing this application, whether you pay a fee for this service or not, that person must print and sign their name in the space below.

Name and Address of Representative (please include the individual name and their company)

(Signature of Individual)		(Print Individual Name)
(Name of Company)		Phone Number (include Area Code)
Street Address, City, State, Zip		Fee Charged or Agreed Upon

Unless the NO box is checked, I give permission for SBA to discuss any portion of this application with the representative listed above. NO •

AGREEMENTS AND CERTIFICATIONS

On behalf of the undersigned individually and for the applicant business:

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.

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.

U.S. Small Business Administration

DISASTER BUSINESS LOAN APPLICATION

If you have questions about this application or problems providing the required information, please contact our Customer Service Center

at 1-800-659-2955 or disastercustomerservice@sba.gov

If more space is needed for any section of this application, please attach additional sheets.

SBA will contact you by phone or E-mail to discuss your loan request.

Filing Requirements

FOR ALL APPLICATIONS, EXCLUDING NON-PROFIT ORGANIZATION, THE FOLLOWING ITEMS MUST BE SUBMITTED.

This application (SBA Form 5), completed and signed

NON-PROFIT• ORGANIZATION (including Houses of Worship, Association, etc), THE FOLLOWING

ITEMS MUST BE SUBMITTED:

This application (SBA Form 5), completed and signed

A complete copy of the organization's most recent tax return OR a copy of the organizations's IRS tax-exempt certification and

• complete copies of the organization's three most recent years' "Statement of Activities"

• Schedule of Liabilities.

Tax Information Authorization (IRS Form 4506-T), completed and signed for each applicant and for any affiliated entity.

•Affiliates include, but are not limited to, business parents, subsidiaries, and/or other businesses with common ownership or management.

ADDITIONAL REQUIREMENTS FOR MILITARY RESERVIST ECONOMIC INJURY (MREIDL);

ADDITIONAL INFORMATION MAY BE NECESSARY TO PROCESS YOUR APPLICATION. IF REQUESTED, PLEASE PROVIDE WITHIN 7 DAYS OF THE INFORMATION REQUEST;

NOTE: PLEASE READ, DETACH AND KEEP FOR YOUR RECORDS

STATEMENTS REQUIRED BY LAWS AND EXECUTIVE ORDERS

To comply with legislation passed by the Congress and Executive Orders issued by the President, Federal executive agencies, including the Small Business Administration (SBA), must notify you of certain information. You can find the regulations and policies implementing these laws and Executive Orders in Title 13, Code of Federal Regulations (CFR), Chapter 1, or our Standard Operating Procedures (SOPs). In order to provide the required notices, the following is a brief summary of the various laws and Executive Orders that affect SBA's Disaster Loan Programs. A glossary of terms can be found at Disasterloan.sba.gov.

FREEDOM OF INFORMATION ACT (5 U.S.C. § 552)

This law provides, with some exceptions, that we must make records or portions of records contained in our files available to persons requesting them. This generally includes aggregate statistical information on our disaster loan programs and other information such as names of borrowers (and their officers, directors, stockholders or partners), loan amounts at maturity, the collateral pledged, and the general purpose of loans. We do not routinely make available to third parties your proprietary data without first notifying you, required by Executive Order 12600, or information that would cause competitive harm or constitute a clearly unwarranted invasion of personal privacy.

Freedom of Information Act (FOIA) requests must describe the specific records you want. For information about the FOIA, contact the Chief, FOI/PA Office, 409 3rd Street, SW, Suite 5900, Washington, DC 20416, or by e-mail at foia@sba.gov.

PRIVACY ACT (5 U.S.C. § 552a)

Anyone can request to see or get copies of any personal information that we have in your file. Any personal information in your file that is retrieved by individual identifiers, such as name or social security number is protected by the Privacy Act, which means requests for information about you may be denied unless we have your written permission to release the information to the requestor or unless the information is subject to disclosure under the Freedom of Information Act. The Agreements and Certifications section of this form contains written permission for us to disclose the information resulting from this collection to state, local or private disaster relief services.

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, on the Disaster Loan Applicants and guarantors for purposes of originating, servicing, and liquidating Disaster loans. See, 69 F.R. 58598, 58617 (and as amended from time to time) for additional background and other routine uses.

Under the provisions of the Privacy Act, you are not required to provide social security numbers. (But see the information under Debt Collection Act below) We use social security numbers to distinguish between people with a similar or the same name for credit decisions and for debt collection purposes. Failure to provide this number may not affect any right, benefit or privilege to which you are entitled by law, but having the number makes it easier for us to more accurately identify to whom adverse credit information applies and to keep accurate loan records.

Note: Any person concerned with the collection, use and disclosure of information, under the Privacy Act may contact the Chief, FOI/ PA Office, 409 3rd Street, SW, Suite 5900, Washington, DC 20416 or by e-mail at foia@sba.gov for information about the Agency's procedures relating to the Privacy Act and the Freedom of Information Act.

DEBT COLLECTION ACT OF 1982; DEFICIT REDUCTION ACT OF 1984; DEBT COLLECTION IMPROVEMENT ACT OF 1996 & other titles (31 U.S.C. 3701 et seq.)

These laws require us to aggressively collect any delinquent loan payments and to require you to give your taxpayer identification number to us when you apply for a loan. If you receive a loan and do not make payments when they become due, we may take one or more of the following actions (this list may not be exhaustive):

*Report the delinquency to credit reporting bureaus.

*Offset your income tax refunds or other amounts due to you from the Federal Government. *Refer the account to a private collection agency or other agency operating a debt collection center. *Suspend or debar you from doing business with the Federal Government.

*Refer your loan to the Department of Justice.

*Foreclose on collateral or take other actions permitted in the loan instruments. *Garnish wages.

*Sell the debt. *Litigate or foreclose.

RIGHT TO FINANCIAL PRIVACY ACT OF 1978 (12 U.S.C. § 3401 et seq.)

This notifies you, as required by the Right to Financial Privacy Act of 1978 (Act), of our right to access financial records held by financial institutions that were or are doing business with you or your business. This includes financial institutions participating in loans or loan guarantees.

The law provides that we may access your financial records when considering or administering Government loan or loan guaranty assistance to you. We must give a financial institution a certificate of our compliance with the Act when we first request access to your financial records. No other certification is required for later access. Our access rights continue for the term of any approved loan or loan guaranty. We do not have to give you any additional notice of our access rights during the term of the loan or loan guaranty.

We may transfer to another Government authority any financial records included in a loan application or about an approved loan or loan guaranty as necessary to process, service, liquidate, or foreclose a loan or loan guaranty. We will not permit any transfer of your financial records to another Government authority except as required or permitted by law.

Paperwork Reduction Act (44 U.S.C. Chapter 35)

We are collecting the information on this form in order to make disaster loans available to qualified small businesses. The form is designed to collect the information necessary for us to make eligibility and credit decisions in order to fund or deny loan requests. We will also use the information collected on this form to produce summary reports for program and management analysis, as required by law.

PLEASE NOTE: The estimated burden for completing this form is 2 hours. Your responses to the requested information are required in order to obtain a benefit under SBA's Disaster Business Loan Programs. However, you are not required to respond to any collection of information unless it displays a currently valid OMB approval number. If you have any questions or comments concerning any aspects of this information collection, please contact the U.S. Small Business Administration Information Branch, 409 3rd St., SW, Washington, DC 20416 and Desk Officer for SBA, Office of Management and Budget, Office of Information and Regulatory Affairs, 725 17th St., NW, Washington, DC 20503. (3245-0017) PLEASE DO NOT SEND FORMS TO OMB.

Policy Concerning Representatives and Their Fees

When you apply for an SBA loan, you may use an attorney, accountant, engineer, appraiser or other representative to help prepare and present the application to us. You are not required to have representation. If an application is approved, you may need an attorney to help prepare closing documents.

There are no "authorized representatives" of SBA, other than our regular salaried employees. Payment of a fee or gratuity to our employees is illegal and will subject those involved to prosecution.

SBA Regulations prohibit representatives from proposing or charging any fee for services performed in connection with your loan unless we consider the services necessary and the amount reasonable. The Regulations also prohibit charging you any commitment, bonus, broker, commission, referral or similar fee. We will not approve the payment of any bonus, brokerage fee or commission. Also, we will not approve placement or finder's fees for using or trying to use influence in the SBA loan application process.

Fees to representatives must be reasonable for services provided in connection with the application or the closing and based upon the time and effort required, the qualifications of the representative, and the nature and extent of work performed. Representatives must execute a compensation agreement.

In the appropriate section of the application, you must state the names of everyone employed by you or on your behalf. You must also notify the SBA disaster office in writing of the names and fees of any representative you employ after you file your application.

If you have any questions concerning payment of fees or reasonableness of fees, contact the Field Office where you filed or will file your application.

Occupational Safety and Health Act (29 U.S.C. 3651 et seq.)

This legislation authorizes the Occupational Safety and Health Administration (OSHA) in the Department of Labor to require businesses to modify facilities and procedures to protect employees when appropriate. If your business does not do so, you may be penalized, forced to close or prevented from starting operations in a new facility. Because of this, we may require information from you to determine whether your business complies with OSHA regulations and may continue operating after the loan is approved or disbursed. You must certify to us that OSHA requirements applying to your business have been determined and that you are, to the best of your knowledge, in compliance.