Paycheck Protection Program
Borrower Application Form Revised February 17, 2021
By Signing Below, You Make the Following Representations, Authorizations, and Certifications
I certify that:
I have read the statements included in this form, including the Statements Required by Law and Executive Orders, and I understand them.
The Applicant is eligible to receive a loan under the rules in effect at the time this application is submitted that have been issued by the Small
Business Administration (SBA) and the Department of the Treasury (Treasury) implementing the Paycheck Protection Program under Division A,
Title I of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) and the Economic Aid to Hard-Hit Small Businesses, Nonprofits,
and Venues Act (the Paycheck Protection Program Rules).
The Applicant, together with its affiliates (if applicable), (1) is an independent contractor, self-employed individual, or sole proprietor with no
employees; (2) if not a housing cooperative, eligible 501(c)(6) organization, or eligible destination marketing organization, employs no more than
the greater of 500 employees or, if applicable, the size standard in number of employees established by SBA in 13 C.F.R. 121.201 for the Applicant’s
industry; (3) if a housing cooperative, eligible 501(c)(6) organization, or eligible destination marketing organization, employs no more than 300
employees; (4) if NAICS 72, employs no more than 500 employees per physical location; (5) if a news organization that is majority owned or
controlled by a NAICS code 511110 or 5151 business or a nonprofit public broadcasting entity with a trade or business under NAICS code 511110
or 5151, employs no more than 500 employees (or, if applicable, the size standard in number of employees established by SBA in 13 C.F.R. 121.201
for the Applicant’s industry) per location; or (6) is a small business under the applicable revenue-based size standard established by SBA in 13
C.F.R. 121.201 for the Applicant’s industry or under the SBA alternative size standard.
I will comply, whenever applicable, with the civil rights and other limitations in this form.
All loan proceeds will be used only for business-related purposes as specified in the loan application and consistent with the Paycheck Protection
Program Rules including the prohibition on using loan proceeds for lobbying activities and expenditures. If Applicant is a news organization that
became eligible for a loan under Section 317 of the Economic Aid to Hard-Hit Small Businesses, Nonprofits, and Venues Act, proceeds of the loan
will be used to support expenses at the component of the business concern that produces or distributes locally focused or emergency information.
I understand that SBA encourages the purchase, to the extent feasible, of American-made equipment and products.
The Applicant is not engaged in any activity that is illegal under federal, state or local law.
Any EIDL loan received by the Applicant (Section 7(b)(2) of the Small Business Act) between January 31, 2020 and April 3, 2020 was for a
purpose other than paying payroll costs and other allowable uses for loans under the Paycheck Protection Program Rules.
For Applicants who are individuals: I authorize the SBA to request criminal record information about me from criminal justice agencies for the purpose of
determining my eligibility for programs authorized by the Small Business Act, as amended.
The authorized representative of the Applicant must certify in good faith to all of the below by initialing next to each one:
The Applicant was in operation on February 15, 2020, has not permanently closed, and was either an eligible self-employed individual,
independent contractor, or sole proprietorship with no employees, or had employees for whom it paid salaries and payroll taxes or paid independent
contractors, as reported on Form(s) 1099-MISC.
Current economic uncertainty makes this loan request necessary to support the ongoing operations of the Applicant.
The funds will be used to retain workers and maintain payroll; or make payments for mortgage interest, rent, utilities, covered operations
expenditures, covered property damage costs, covered supplier costs, and covered worker protection expenditures as specified under the Paycheck
Protection Program Rules; I understand that if the funds are knowingly used for unauthorized purposes, the federal government may hold me
legally liable, such as for charges of fraud.
I understand that loan forgiveness will be provided for the sum of documented payroll costs, covered mortgage interest payments, covered rent
payments, covered utilities, covered operations expenditures, covered property damage costs, covered supplier costs, and covered worker
protection expenditures, and not more than 40% of the forgiven amount may be for non-payroll costs. If required, the Applicant will provide to
the Lender and/or SBA documentation verifying the number of full-time equivalent employees on the Applicant’s payroll as well as the dollar
amounts of eligible expenses for the covered period following this loan.
The Applicant has not and will not receive another loan under the Paycheck Protection Program, section 7(a)(36) of the Small Business Act (15
U.S.C. 636(a)(36)) (this does not include Paycheck Protection Program second draw loans, section 7(a)(37) of the Small Business Act (15 U.S.C.
The Applicant has not and will not receive a Shuttered Venue Operator grant from SBA.
_____ The President, the Vice President, the head of an Executive department, or a Member of Congress, or the spouse of such person as determined
under applicable common law, does not directly or indirectly hold a controlling interest in the Applicant, with such terms having the meanings
provided in Section 322 of the Economic Aid to Hard-Hit Small Businesses, Nonprofits, and Venues Act.
_____ The Applicant is not an issuer, the securities of which are listed on an exchange registered as a national securities exchange under section 6 of the
Securities Exchange Act of 1934 (15 U.S.C. 78f).
I further certify that the information provided in this application and the information provided in all supporting documents and forms is true and
accurate in all material respects. I understand that knowingly making a false statement to obtain a guaranteed loan from SBA is punishable under
the law, including under 18 U.S.C. 1001 and 3571 by imprisonment of not more than five years and/or a fine of up to $250,000; under 15 U.S.C.
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 U.S.C. 1014 by imprisonment of not more than thirty years and/or a fine of not more than $1,000,000.
I acknowledge that the Lender will confirm the eligible loan amount using required documents submitted. I understand, acknowledge, and agree
that the Lender can share any tax information that I have provided with SBA’s authorized representatives, including authorized representatives of
the SBA Office of Inspector General, for the purpose of compliance with SBA Loan Program Requirements and all SBA reviews.
Signature of Authorized Representative of Applicant
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