_____________________________________________________ ____________________________
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Paycheck Protection Program
PPP Loan Forgiveness Application Form 3508EZ
By Signing Below, You Make the Following Representations and Certifications on Behalf of the Borrower:
The Authorized Representative of the Borrower certifies to all of the below by initialing next to each one.
_____ The dollar amount for which forgiveness is requested:
• was used to pay costs that are eligible for forgiveness (payroll costs to retain employees; business mortgage interest
payments; business rent or lease payments; or business utility payments);
• includes payroll costs equal to at least 60% of the forgiveness amount;
• if a 24-week Covered Period applies, does not exceed 2.5 months’ worth of 2019 compensation for any owner-
employee or self-employed individual/general partner, capped at $20,833 per individual; and
• if the Borrower has elected an 8-week Covered Period, does not exceed 8 weeks’ worth of 2019 compensation for
any owner-employee or self-employed individual/general partner, capped at $15,385 per individual.
_____ I understand that if the funds were knowingly used for unauthorized purposes, the federal government may pursue recovery
of loan amounts and/or civil or criminal fraud charges.
_____ The Borrower did not reduce salaries or hourly wages by more than 25 percent for any employee during the Covered Period
or Alternative Payroll Covered Period compared to the period between January 1, 2020 and March 31, 2020. For purposes
of this certification, the term “employee” includes only those employees that did not receive, during any single period during
2019, wages or salary at an annualized rate of pay in an amount more than $100,000.
_____ The Borrower has accurately verified the payments for the eligible payroll and nonpayroll costs for which the Borrower is
requesting forgiveness.
_____ I have submitted to the Lender the required documentation verifying payroll costs, the existence of obligations and service
(as applicable) prior to February 15, 2020, and eligible business mortgage interest payments, business rent or lease payments,
and business utility payments.
_____ The information provided in this application and the information provided in all supporting documents and forms is true
and correct in all material respects. I understand that knowingly making a false statement to obtain forgiveness of an SBA-
guaranteed loan is punishable under the law, including 18 USC 1001 and 3571 by imprisonment of not more than five years
and/or a fine of up to $250,000; under 15 USC 645 by imprisonment of not more than two years and/or a fine of not more
than $5,000; and, if submitted to a Federally insured institution, under 18 USC 1014 by imprisonment of not more than thirty
years and/or a fine of not more than $1,000,000.
_____
The tax documents I have submitted to the Lender are consistent with those the Borrower has submitted/will submit to
the IRS and/or state tax or workforce agency. I also understand, acknowledge, and agree that the Lender can share the
tax information with SBA’s authorized representatives, including authorized representatives of the SBA Office of
Inspector General, for the purpose of ensuring compliance with PPP requirements and all SBA reviews.
_____
I understand, acknowledge, and agree that SBA may request additional information for the purposes of evaluating the
Borrower’s eligibility for the PPP loan and for loan forgiveness, and that the Borrower’s failure to provide information
requested by SBA may result in a determination that the Borrower was ineligible for the PPP loan or a denial of the
Borrower’s loan forgiveness application.
In addition,
the Authorized Representative of the Borrower must certify by initialing at least ONE of the following two items:
_____ The Borrower did not reduce the number of employees or the average paid hours of employees between January 1, 2020 and
the end of the Covered Period (other than any reductions that arose from an inability to rehire individuals who were
employees on February 15, 2020, if the Borrower was unable to hire similarly qualified employees for unfilled positions on
or before December 31, 2020, and reductions in an employee’s hours that a borrower offered to restore and were refused).
_____ The Borrower was unable to operate between February 15, 2020, and the end of the Covered Period at the same level of
business activity as before February 15, 2020 due to compliance with requirements established or guidance issued between
March 1, 2020 and December 31, 2020, by the Secretary of Health and Human Services, the Director of the Centers for
Disease Control and Prevention, or the Occupational Safety and Health Administration, related to the maintenance of
standards of sanitation, social distancing, or any other work or customer safety requirement related to COVID-19.
The Borrower’s eligibility for loan forgiveness will be evaluated in accordance with the PPP regulations and guidance issued by
SBA through the date of this application. SBA may direct a lender to disapprove the Borrower’s loan forgiveness application if SBA
determines that the Borrower was ineligible for the PPP loan.
Signature of Authorized Representative of Borrower Date
Print Name Title
SBA Form 3508EZ (06/20)
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