SBA PPP Loan Number: ________________________ Lender PPP Loan Number: __________________________
PPP Loan Amount: _____________________________ PPP Loan Disbursement Date: ________________________
Employees at Time of Loan Application: ___________ Employees at Time of Forgiveness Application: __________
EIDL Advance Amount: ________________________ EIDL Application Number: __________________________
Forgiveness Amount: ___________________________
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 does not exceed the principal amount of the PPP loan and:
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 has accurately verified the payments for the eligible payroll and nonpayroll costs for which the Borrower is
requesting forgiveness, and has accurately calculated the forgiveness amount requested.
_____ 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.
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
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