Paycheck Protection Program
Borrower Application Form Revised June 24, 2020
Purpose of this form:
This form is to be completed by the authorized representative of the Applicant and submitted to your SBA Participating Lender. Submission of the
requested information is required to make a determination regarding eligibility for financial assistance. Failure to submit the information would affect
that determination.
Instructions for completing this form:
With respect to “purpose of the loan,” payroll costs consist of compensation to employees (whose principal place of residence is the United States) in
the form of salary, wages, commissions, or similar compensation; cash tips or the equivalent (based on employer records of past tips or, in the absence
of such records, a reasonable, good-faith employer estimate of such tips); payment for vacation, parental, family, medical, or sick leave; allowance for
separation or dismissal; payment for the provision of employee benefits consisting of group health care coverage, including insurance premiums, and
retirement; payment of state and local taxes assessed on compensation of employees; and for an independent contractor or sole proprietor, wage,
commissions, income, or net earnings from self-employment or similar compensation.
For purposes of calculating “Average Monthly Payroll,” most Applicants will use the average monthly payroll for 2019, excluding costs over $100,000
on an annualized basis for each employee. For seasonal businesses, the Applicant may elect to instead use average monthly payroll for the time period
between February 15, 2019 and June 30, 2019 or any 12-week period between May 1, 2019 and September 15, 2019, excluding costs over $100,000
on an annualized basis for each employee. For new businesses, average monthly payroll may be calculated using the time period from January 1, 2020
to February 29, 2020, excluding costs over $100,000 on an annualized basis for each employee.
If Applicant is refinancing an Economic Injury Disaster Loan (EIDL): Add the outstanding amount of an EIDL made between January 31, 2020 and
April 3, 2020, less the amount of any “advance” under an EIDL COVID-19 loan, to Loan Request as indicated on the form.
All parties listed below are considered owners of the Applicant as defined in 13 CFR § 120.10, as well as “principals”:
• For a sole proprietorship, the sole proprietor;
•
For a partnership, all general partners, and all limited partners owning 20% or more of the equity of the firm;
•
For a corporation, all owners of 20% or more of the corporation;
• For limited liability companies, all members owning 20% or more of the company; and
• Any Trustor (if the Applicant is owned by a trust).
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 time for completing this application, including gathering data needed, is 8 minutes. Comments about this time or the information
requested should be sent to: 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, Washington DC 20503. PLEASE DO NOT SEND FORMS
TO THESE ADDRESSES.
Privacy Act (5 U.S.C. 552a) – Under the provisions of the Privacy Act, you are not required to provide your social security number. Failure to provide
your social security number may not affect any right, benefit or privilege to which you are entitled. (But see Debt Collection Notice regarding taxpayer
identification number below.) Disclosures of name and other personal identifiers are required to provide SBA with sufficient information to make a
character determination. When evaluating character, SBA considers the person’s integrity, candor, and disposition toward criminal actions.
Additionally, SBA is specifically authorized to verify your criminal history, or lack thereof, pursuant to section 7(a)(1)(B), 15 USC Section 636(a)(1)(B)
of the Small Business Act (the Act).
Disclosure of Information – Requests for information about another party may be denied unless SBA has the written permission of the individual to
release the information to the requestor or unless the information is subject to disclosure under the Freedom of Information Act. The Privacy Act
authorizes SBA to make certain “routine uses” of information protected by that Act. One such routine use is the disclosure of information maintained
in SBA’s system of records when this information indicates a violation or potential violation of law, whether civil, criminal, or administrative in nature.
Specifically, SBA may refer the information 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 is disclosure to other Federal
agencies conducting background checks but only to the extent the information is relevant to the requesting agencies' function. See, 74 F.R. 14890
(2009), and as amended from time to time for additional background and other routine uses. In addition, the CARES Act, requires SBA to register
every loan made under the Paycheck Protection Act using the Taxpayer Identification Number (TIN) assigned to the borrower.
Debt Collection Act of 1982, Deficit Reduction Act of 1984 (31 U.S.C. 3701 et seq. and other titles) – 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: (1) report the status of your loan(s)
to credit bureaus, (2) hire a collection agency to collect your loan, (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 (6) foreclose on collateral or take other action permitted in the loan instruments.
