Sba Form 5C – Fill Out and Use

SBA Internal Use Only:

Date Received

Location

By

SBA Application Number:

FEMA Registration Number:

Filing Deadline:

Declaration Number:

ARE YOU APPLYING FOR:

Primary Residence

Sole Proprietor - Physical Damage

Sole Proprietor - Economic Injury

INFORMATION ABOUT THE APPLICANT(S)

Primary Applicant

Joint Applicant

First Name

Middle Name

First Name

Middle Name

Last Name

Suffix

Last Name

Suffix

Social SecurityNumber

Date of Birth

Social SecurityNumber

Date of Birth

Household Size

Marital Status

Married

Not Married

Marital Status

Married

Not Married

Are you a U.S. Citizen?

Are you a U.S. Citizen?

Yes

No

Yes

No

AreyouanSBA Employee?

Yes

No

AreyouanSBA Employee?

Yes

No

CONTACT INFORMATION

INCOME INFORMATION

Primary Applicant

Joint Applicant

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DEBTS

I have no debts

Mortgage Holder or Landlord's Name (Primary Residence)

MonthlyPayment/Rent

Current Balance

Name

$

$

2nd MortgageHolderName(ifapplicable)

MonthlyPayment/Rent

Current Balance

Name

$

$

Note: Please complete the section below if the amounts are NOT included in your mortgage payment:

RealEstateTaxes

Homeowner's Insurance

Condo/Townhome/HOA/Co-Op Fees

$

per year

$

per year

$

per year

OtherDebtincludingautopayments,creditcards,installmentloans,studentloans,etc.

Note: Only include debts that will last longer than 10 months.

Nameof Creditor

Monthly Payment

Current Balance

INSURANCE INFORMATION

Pleasecheckallinsuranceinforceforthedamagedproperty:

(describe)

Homeowner's

Flood

Automobile

Renter's

NoInsurance

Other:

PolicyType

Insurance Company Name

PolicyNumber

PhoneNumber

Amount Received

$

$

$

OTHER DISASTER ASSISTANCE

Other than FEMA, have you received any grant award (i.e. city grants, county grants, state grants, etc.):

Yes

No

ASSETS

Pre-disaster values:

Cash, Bank Accounts and Marketable Securities (e.g. Stock & Bonds, CDs, etc.) (Not including retirement accounts) . . . . . . . . . . . . . . . . . . . ... . . .. . $ Retirement Accounts (e.g. IRAs, Keogh, TSP or other similar accounts). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ... . .$ Personal Property (furniture, appliances, vehicles, RVs, etc.). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$

Primary Residence	$
All Other Real Estate (describe)	$

DISCLOSURES

The responses below apply to the Applicant and Joint Applicant, if any. Please explain any "Yes" responses on the last page.

1.	. . . . . .. .Are you delinquent on any Federal taxes, Federal loans, Federal grants, or 60 days past due on any child support obligation?				Yes		No
2.	. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .Are you currently a defendant in any lawsuits or have pending judgements against you?				Yes		No
3.	....................AreyoucurrentlysuspendedordebarredfromcontractingwithFederalgovernmentorreceivingFederalgrantsorloans?				Yes		No
4.	. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..Do you have federal loans, federally guaranteed loans, or previous SBA loans?				Yes		No
5. Are you engaged in the productionor distribution of any product that has been determined to be obscene by a court of competent					Yes		No
	jurisdiction?
		. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
6.	. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .In the past year, have you been convicted of a felony committed in connection with a riot or civil disorder?				Yes		No
7.	Areyoupresently, a)subject toan indictment,criminal information, arraignment, orothermeans by whichformalcriminal charges arebrought inany
	jurisdiction;b)haveyoubeenarrestedinthepastsixmonthsforanycriminaloffense;c)foranycriminaloffense-otherthanaminorvehicleviolation				Yes		No
	-- haveyouever:1)beenconvicted,2)pleadguilty,3)pleadnolocontendere,4)beenplacedonpretrialdiversion,or5)beenplacedonanyformof
	. . . . . . . . . . . . .parole or probation (including probation before judgment)?	. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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REPRESENTATIVE INFORMATION

If you have paid a representative (packager, attorney, accountant, etc.) to assist you in completing the application, please complete the section below:

NameandAddressofRepresentative:	Fee charged or agreed upon
	$

CONSENT

I authorize my insurance company, bank, financial institution, or other creditors to release to SBA all records and financial information necessary to process this application.

SBA has my permission, 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.RedCross,SalvationArmy, MennoniteDisasterServices,SBAResource Partners)forthepurposeof assistingme withmySBA application, evaluatingmyeligibilityforadditional disaster assistance, or notifying me of the availability of such assistance.

If my loan is approved, I may be eligible for additional funds to safeguard my property from damages similar to those caused by this disaster. Although it is not necessary for me to provide with my application, a description and cost estimate will be required prior to SBA approval of the mitigation measure.

I have received and read a copy of the "STATEMENTS REQUIRED BY LAWS AND EXECUTIVE ORDERS" which was attached to this application.

CERTIFICATIONASTOTRUTHFULINFORMATION:Bysigningthisapplication,youcertifythatallinformationin yourapplicationandsubmitted with yourapplicationistrueandcorrectto 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 limitedto: 1)finesandimprisonment,orboth,under15U.S.C.645,18U.S.C.1001,18U.S.C.1014,18U.S.C.1040,18U.S.C.3571,andanyotherapplicablelaws;2)trebledamagesandcivil 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 of2015.

Signature of Applicant

Date

Signature of Joint Applicant

Date

ADDITIONAL COMMENTS

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U.S. Small Business Administration

DISASTER HOME 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 Email to discuss your loan request.

FILING REQUIREMENTS

REQUIRED FOR ALL LOAN APPLICATIONS:

■Complete and sign this application form (SBA Form 5C)

■Complete and sign the Tax Information Authorization (IRS Form 4506T) enclosed with this application. This income information, obtained from the IRS, will help us determine your repayment ability. U.S. Territories that have their own taxing authority outside of the IRS may require additional form(s) in order to obtain copies of their transcripts. The exact form(s) required will be determined at the onset of the declared disaster. All other filing requirements remain the same.

WHILE NOT NECESSARY TO ACCEPT YOUR APPLICATION, YOU MAY BE REQUIRED TO SUPPLY THE FOLLOWING INFORMATION TO PROCESS THE APPLICATION. IF REQUESTED, PLEASE PROVIDE WITHIN 7 DAYS OF THE INFORMATION REQUEST:

■If any applicant has changed employment within the past two years, provide a copy of a current (within 1 month of the application date) pay stub for all applicants

■If we need additional income information, you may be asked to provide copies of your

Federal income tax returns, including all schedules

IF SBA APPROVES YOUR LOAN, WE MAY REQUIRE THE FOLLOWING ITEMS BEFORE LOAN CLOSING. WE WILL ADVISE YOU, IN WRITING, OF THE DOCUMENTS WE NEED.

■If you own your residence, a COMPLETE legible copy of the deed, including the legal description of the property

■If the damaged property is your primary residence, proof of residency at the damaged address

■If you had damage to a manufactured home, a copy of the title. If you own the lot where the home is located, a COMPLETE legible copy of the deed, including the legal description of the property

■If you have damage to an automobile or other vehicle, proof of ownership (a copy of the registration, title, bill of sale, etc.)

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NOTE: PLEASE READ, DETACH AND KEEP FOR YOUR RECORDS

STATEMENTS REQUIRED BY LAWS AND EXECUTIVE ORDERS

TocomplywithlegislationpassedbytheCongressandExecutiveOrdersissuedbythePresident,Federalexecutiveagencies, includingtheSmallBusinessAdministration(SBA),mustnotifyyouofcertaininformation.Youcanfindtheregulationsandpolicies implementing these laws and Executive Orders in Title 13, Code of Federal Regulations (CFR), Chapter 1, or our Standard Operating Procedures(SOPs).Inordertoprovidetherequirednotices,thefollowingisabriefsummaryofthevariouslawsandExecutive 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 suchasnames of borrowers (andtheirofficers,directors,stockholders orpartners),loanamounts at maturity,the collateral pledged, and the general purpose of loans.Wedo not routinely make available to third parties your proprietary data withoutfirstnotifyingyou,asrequiredbyExecutiveOrder#12600,orinformationthatwouldcausecompetitive harmorconstitute a clearly unwarranted invasion of personal privacy.

FreedomofInformationAct(FOIA)requestsmustdescribethespecificrecordsyouwant.ForinformationabouttheFOIA,contact the Chief, FOI/PA Office, 4093rd Street, SW, Suite 5900,Washington, DC 20416, or by e-mail at foia@sba.gov.

PRIVACY ACT (5 U.S.C. § 552a)

Anyonecanrequestto seeor getcopies of anypersonal informationthat wehavein your file.Anypersonal informationinyourfile that is retrieved by individual identifiers, such asname or social security number is protected bythe 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.

ThePrivacyActauthorizesSBAtomakecertain"routineuses"ofinformationprotectedbythatAct.OnesuchroutineuseforSBA'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 responsibilityfororotherwiseinvolvedininvestigation,prosecution,enforcementorpreventionofsuchviolations.Anotherroutine use of personal information isto assist in obtaining credit bureau reports, on the Disaster Loan Applicants and guarantors for purposesoforiginating,servicing,andliquidatingDisasterloans.See,69F.R.58598,58617(andasamendedfromtimetotime)for additional background and other routine uses.

UndertheprovisionsofthePrivacyAct,youarenotrequiredtoprovidesocialsecuritynumbers.(Butseetheinformationunder DebtCollectionActbelow)Weusesocialsecuritynumberstodistinguish betweenpeoplewithasimilarorthesamenamefor credit decisions andfor debt collection purposes. Failure toprovide this number may not affectanyright, benefit or privilege to which you are entitled bylaw, 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.

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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 theybecome 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.)

Thisnotifiesyou,asrequiredbytheRighttoFinancialPrivacyActof1978(Act),ofourrighttoaccessfinancialrecords heldbyfinancialinstitutionsthatwereoraredoingbusinesswithyouoryourbusiness.Thisincludesfinancialinstitutions participating in loans or loan guarantees.

ThelawprovidesthatwemayaccessyourfinancialrecordswhenconsideringoradministeringGovernmentloanorloan guarantyassistancetoyou.Wemustgiveafinancial institutionacertificate of ourcompliancewiththeActwhenwefirst requestaccesstoyourfinancialrecords.Noothercertificationisrequiredforlateraccess.Ouraccessrightscontinuefor 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 approvedloanorloanguarantyasnecessarytoprocess,service,liquidate,orforeclosealoanorloanguaranty.Wewill notpermitanytransferof your financial recordstoanother Governmentauthorityexceptasrequiredorpermitted bylaw.

CONSUMER CREDIT PROTECTION ACT (15 U.S.C. 1601 et seq.)

This legislation gives an applicant who is refused creditbecause of adverse information about the applicant's credit, reputation,characterormode oflivinganopportunitytorefuteorchallengetheaccuracyofsuchreports.Therefore,ifwe decline your loan in whole or in part because of adverse information in a credit report, you will be given the name and address of the reporting agency so you can seek to have that agency correct its report, if inaccurate. If we decline your loaninwholeorinpart becauseof adverseinformationreceivedfromasourceother thana creditreportingagency, you will be given information but not the source of the report.

Within3daysaftertheconsummation of thetransaction,anyrecipientof anSBAloanwhichissecuredinwholeorinpart byalienontherecipient'sresidenceorhouseholdcontentsmayrescindsuchaloaninaccordancewith"RegulationZ"of the Federal Reserve Board.

PLEASE NOTE: The estimated burden for completing this form is 1.25 hours. Your responses to the requested information are required in order to obtain a benefit under our Disaster Home Loan Program. However, you are not required to respondtoanycollectionofinformation unlessitdisplaysacurrentlyvalidOMBapprovalnumber.Ifyouhavequestions or comments concerning any aspects of this information collection, please contact the U.S. Small Business Administration InformationBranch,4093rdStreet,SW,Washington,DC20416andDeskOfficerforSBA,OfficeofManagementand Budget, Office ofInformation and Regulatory Affairs, 725 17th Street,NW,Washington, DC20503. (3245-0018)PLEASE DO NOT SEND FORMS TO OMB.

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