Paycheck Protection Program
Borrower Application Form Revised March 18, 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), the Economic Aid to Hard-Hit Small Businesses, Nonprofits, and
Venues Act, and Title V of the American Rescue Plan Act of 2021 (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, other eligible 501(c) 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, employs no more than 300 employees; (4) if an eligible 501(c)(6)
organization, other eligible 501(c) organization, or eligible destination marketing organization, employs no more than 300 employees per physical
location; (5) if NAICS 72 or a 501(c)(3) organization, employs no more than 500 employees per physical location; (6) if a news organization that
is majority owned or controlled by a NAICS code 511110 or 5151 business, a nonprofit public broadcasting entity with a trade or business under
NAICS code 511110 or 5151, or an Internet-only news or periodical publisher assigned NAICS code 519130 and engaged in the collection and
distribution of local or regional and national news and information, 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 (7) 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
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.
If the Applicant is an Internet-only news or periodical publisher that became eligible for a loan under Section 5001 of the American Rescue Plan
Act of 2021, the proceeds of the loan will be used to support expenses at the component of the business or organization that supports local or
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 been approved for a Shuttered Venue Operator (SVO) grant from SBA as of the date of this loan application, and the
Applicant acknowledges that if the Applicant is approved for an SVO grant before SBA issues a loan number for this loan, the Applicant is
ineligible for the loan and acceptance of any loan proceeds will be considered an unauthorized use.
_____ 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).