Fillable Paycheck Protection Program Borrower Application Form for Schedule (Lendistry)

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Paycheck Protection Program Borrower Application Form for Schedule (Lendistry)

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Paycheck Protection Program
Borrower Application Form for Schedule C Filers Using Gross Income
Revised March 18, 2021
OMB Control No.: 3245-0407
Expiration Date: 9/30/2021
AN APPLICANT MAY USE THIS FORM ONLY IF THE APPLICANT FILES AN IRS FORM 1040, SCHEDULE C, AND
USES GROSS INCOME TO CALCULATE PPP LOAN AMOUNT
Check One: Sole proprietor
Independent contractor
Self-employed individual
Single member LLC (self-employed
individual)
Qualified joint venture (self-employed
individual)
DBA or Tradename (if applicable)
Year of Establishment (if applicable)
Business Legal Name NAICS Code
Applicant (including affiliates, if
applicable) Meets Size Standard (check
one):
No more than 500 employees (or 300
employees, if applicable)
unless “per
location” exception applies
SBA industry size standards
SBA alternative size standard
Business Address (Street, City, State, Zip Code - No P.O. Box
addresses allowed)
Business TIN (EIN, SSN, ITIN) Business Phone
Primary Contact
Email Address
Total Amount of Gross Income
(from IRS Form 1040, Schedule C, Line 7)
$
Tax Year Used for Gross
Income
2019
2020
Number of Employees
(including owners):
If you do not have any employees (other than owners), complete this table:
A. Your gross income
amount from 2019 or 2020
IRS Form 1040, Schedule
C, line 7:
$
B. Divide A by 12 (if
more than $8,333.33,
enter $8,333.33):
$
x 2.5 + EIDL (Do Not
Include Any EIDL
Advance) equals Loan
Request Amount:
$
If you have employees (other than owners), complete this table:
A. Your 2019 or 2020 IRS
Form 1040, Schedule C,
line 7
amount, minus the
sum of line
14, line
19, and
line 26:
$
B. D
ivide A by 12 (if
more than $8,333.33,
enter $8,333.33):
$
C. Average Monthly
Payroll for Employees
(not including owners)
$
Add B and C: $
x 2.5 + EIDL (Do Not Include Any EIDL
Advance) equals Loan Request Amount:
$
Purpose of the loan
(select all that
apply):
☐
Payroll Costs (including
proprietor expenses, equal to
business expenses plus owner
compensation)
☐
Rent /
Mortgage
Interest
☐
Utilities
☐
Covered Operations
Expenditures
☐
Covered Property
Damage
☐
Covered
Supplier Costs
☐
Covered Worker
Protection Expenditures
Other (explain):
______________________
Applicant Ownership
List all owners of 20% or more of the equity of the Applicant. Attach a separate sheet if necessary.
Owner Name
Title
Ownership %
TIN (EIN, SSN,
ITIN)
Address
1
SBA Form 2483-C (3/21)
PPP Applicant Demographic Information (Optional)
Veteran/gender/race/ethnicity data is collected for program reporting purposes only. Disclosure is voluntary and will have no bearing on the
loan application decision.
Principal Name
Principal Position
Select Response Below:
Veteran
☐
Non-Veteran;
☐
Veteran;
☐
Service-Disabled Veteran;
☐
Spouse of Veteran;
☐
Not Disclosed
Gender
☐
Male;
☐
Female;
☐
Not Disclosed
Race (more than 1
may be selected)
☐
American Indian or Alaska Native;
☐
Asian;
☐
Black or African-American;
☐
Native Hawaiian or Pacific Islander;
☐
White;
☐
Not Disclosed
Ethnicity
☐
Hispanic or Latino;
☐
Not Hispanic or Latino;
☐
Not Disclosed
If questions (1), (2), (5), or (6) are answered “Yes,” the loan will not be approved.
Question Yes No
1. Is the Applicant or any owner of the Applicant presently suspended, debarred, proposed for debarment, declared ineligible,
voluntarily excluded from participation in this transaction by any Federal department or agency, or presently involved in any
bankruptcy?
2. Has the Applicant, any owner of the Applicant, or any business owned or controlled by any of them, ever obtained a direct or
guaranteed loan from SBA or any other Federal agency (other than a Federal student loan
made or guaranteed through a program
administered by the Department of Education) that is (a) currently delinquent, or (b) has defaulted in the last 7 years and caused a loss
to the government?
3. Is the Applicant or any owner of the Applicant an owner of any other business, or have common management (including a
management agreement) with any other business? If yes, list all such businesses (including their TINs if available) and describe the
relationship on a separate sheet identified as addendum A.
4. Did the Applicant receive an SBA Economic Injury Disaster Loan between January 31, 2020 and April 3, 2020? If yes, provide
details on a separate sheet identified as addendum B.
5. Is the Applicant (if an individual) or any owner of the Applicant presently incarcerated or, for any felony, presently subject to an
indictment, criminal information, arraignment, or other means by which formal criminal charges are brought in any jurisdiction?
Initial here to confirm your response to question 5
→ _____________________
6. Within the last 5 years, for any felony involving fraud, bribery, embezzlement, or a false statement in a loan application or an
application for federal financial assistance, has the Applicant (if an individual) or any owner of the Applicant 1) been convicted; 2)
pleaded guilty; 3) pleaded nolo contendere; or 4) commenced any form of parole or probation (including probation before judgment)?
Initial here to confirm your response to question 6 → _____________________
7. Is the United States the principal place of residence for the owner(s) of the Applicant and all employees included in the Applicant’s
payroll calculation above?
8. Is the Applicant a franchise?
9. Is the franchise listed in SBA’s Franchise Directory? If yes, enter SBA Franchise Identifier Code here:
_______________
2
SBA Form 2483-C (3/21)
Paycheck Protection Program
Borrower Application Form for Schedule C Filers Us
ing Gross Income
Revised
M
arch 18, 2021
Paycheck Protection Program
Borrower Application Form for Schedule C Filers Using Gross Income
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) 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 NAICS 72, employs no more than 500 employees per physical location; (4) if 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 the size standard in number of employees established by SBA in 13 C.F.R. 121.201
for the Applicant’s industry) per physical location; or (5) 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 (including payroll and other proprietor expenses, which is business expenses plus
owner compensation, as defined in the interim final rule posted on March 3, 2021) 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 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 regional news.
•
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 terms “payroll” and
“payroll costs” as used in the below certifications include proprietor expenses (business expenses plus owner compensation)):
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.
636(a)(37)).
The Applicant has not been approved for a Shuttered Venue Operator (SVO) grant from SBA as of the date of this 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).
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.
3
SBA Form 2483-C (3/21)
Paycheck Protection Program
Borrower Application Form for Schedule C Filers Using Gross Income
Revised March 18, 2021
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 Date
___________________________________________ ________________________
Print Name Title
4
SBA Form 2483-C (3/21)
click to sign
signature
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Paycheck Protection Program
Borrower Application Form for Schedule C Filers Using Gross Income
Revised March 18, 2021
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.
An Applicant that files an IRS Form 1040, Schedule C, and elects to calculate the PPP loan amount using gross income must use this form. An Applicant
that files an IRS Form 1040, Schedule C, and elects to calculate the PPP loan amount using net profit must use SBA Form 2483. An Applicant that files an
IRS Form 1040, Schedule F, and calculates the PPP loan amount using gross income must use SBA Form 2483.
Instructions for completing this form:
For purposes of reporting Year of Establishment, applicants may enter “NA”.
For purposes of reporting NAICS Code, applicants must match the business activity code provided on their IRS income tax filings, if applicable.
For purposes of reporting Number of Employees, sole proprietors, self-employed individuals, and independent contractors should include themselves as
employees (i.e., the minimum number in the box Number of Employees is one). Applicants may use their average employment over the time period used to
calculate their aggregate payroll costs to determine their number of employees. Alternatively, Applicants may elect to use the average number of employees
per pay period in the 12 completed calendar months prior to the date of the loan application.
For purposes of calculating Average Monthly Payroll for Employees (box C), Applicants must use the average monthly payroll for 2019 or 2020 for
employees (not including the owner), excluding costs over $100,000 on an annualized basis, as prorated for the period during which the payments are made
or the obligation to make the payments is incurred, for each employee. The payroll year used must be the same as the tax year used for the gross income
calculation (box A in either table). For seasonal businesses, the Applicant may elect to instead use average total monthly payroll for any twelve-week period
selected by the Applicant between February 15, 2019 and February 15, 2020, excluding costs over $100,000 on an annualized basis, as prorated for the
period during which the payments are made or the obligation to make the payments is incurred, 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, as
prorated for the period during which the payments are made or the obligation to make the payments is incurred, 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 to Loan Request as indicated on the form. Do not add the amount of any EIDL Advance.
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 (except those paid leave
amounts for which a credit is allowed under FFCRA Sections 7001 and 7003); allowance for separation or dismissal; payment for the provision of employee
benefits (including insurance premiums) consisting of group health care coverage, group life, disability, vision, or dental insurance, and retirement benefits;
payment of state and local taxes assessed on compensation of employees; and wages, commissions, income, or net earnings from self-employment or similar
compensation. This includes proprietor expenses, which means businesses expenses plus owner compensation.
If the Applicant is a qualified joint venture for federal income tax purposes ((1) the only members of the joint venture are a married couple who file a joint
return and each file Schedule C, (2) both spouses materially participate in the trade or business, and (3) both spouses elect not to be treated as a partnership),
only one spouse may submit this form on behalf of the qualified joint venture. For purposes of reporting Number of Employees, each spouse should be
counted. For purposes of determining which table to use to calculate Loan Request Amount, if the Applicant has no employees other than the married couple,
complete the table labeled “If you do not have any employees other than yourself, complete this table.” For purposes of calculating gross income, enter the
sum of gross income (Schedule C, line 7) from both spouses. For purposes of calculating the Loan Request Amount, the amount entered in box B in either
table is capped at $8,333.33.
For a sole proprietorship, the sole proprietor is considered the owner of the Applicant. For a limited liability company that has only one member and that is
treated as a disregarded entity for federal income tax purposes and files Schedule C, the member is considered a sole proprietor and the owner of the
Applicant. If the Applicant is treated as a qualified joint venture for federal income tax purposes (the only members of the joint venture are a married couple
who file a joint return and each file a Schedule C), both spouses are considered sole proprietors and owners of the Applicant.
For purposes of reporting (optional) demographic information:
1. Purpose. Veteran/gender/race/ethnicity data is collected for program reporting purposes only.
2. Description. This form requests information about each of the Applicant’s Principals. Add additional sheets if necessary.
3. Definition of Principal. The term “Principal” means:
• The self-employed individual, independent contractor, or sole proprietor.
• Any individual hired by the Applicant to manage the day-to-day operations of the Applicant (“key employee”).
4. Principal Name. Insert the full name of the Principal.
5. Principal Position. Identify the Principal’s position: self-employed individual, independent contractor, sole proprietor, or key employee.
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.
5
SBA Form 2483-C (3/21)
Paycheck Protection Program
Borrower Application Form for Schedule C Filers Using Gross Income
Revised March 18, 2021
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 U.S.C. Section 636(a)(1)(B) of the Small Business
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
Program 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) take
other action permitted in the loan instruments.
Right to Financial Privacy Act of 1978 (12 U.S.C. 3401) – The Right to Financial Privacy Act of 1978, grants SBA access rights to financial records held
by financial institutions that are or have been doing business with you or your business including any financial institutions participating in a loan or loan
guaranty. SBA is only required provide a certificate of its compliance with the Act to a financial institution in connection with its first request for access to
your financial records. SBA’s access rights continue for the term of any approved loan guaranty agreement. SBA is also authorized to transfer to another
Government authority any financial records concerning an approved loan or loan guarantee, as necessary to process, service or foreclose on a loan guaranty
or collect on a defaulted loan guaranty.
Freedom of Information Act (5 U.S.C. 552) – This law provides, with some exceptions, that SBA must supply information reflected in agency files and
records to a person requesting it. Information about approved loans that is generally released includes, among other things, statistics on our loan programs
(individual borrowers are not identified in the statistics) and other information such as the names of the borrowers, the amount of the loan, and the type of
the loan. Proprietary data on a borrower would not routinely be made available to third parties. All requests under this Act are to be addressed to the nearest
SBA office and be identified as a Freedom of Information request.
Occupational Safety and Health Act (15 U.S.C. 651 et seq.) – The Occupational Safety and Health Administration (OSHA) can require businesses to
modify facilities and procedures to protect employees. Businesses that do not comply may be fined and required to abate the hazards in their workplaces.
They may also be ordered to cease operations posing an imminent danger of death or serious injury until employees can be protected. Signing this form is
certification that the applicant, to the best of its knowledge, is in compliance with the applicable OSHA requirements, and will remain in compliance during
the life of the loan.
Civil Rights (13 C.F.R. 112, 113, 117) – All businesses receiving SBA financial assistance must agree not to discriminate in any business practice, including
employment practices and services to the public on the basis of categories cited in 13 C.F.R., Parts 112, 113, and 117 of SBA Regulations. All borrowers
must display the "Equal Employment Opportunity Poster" prescribed by SBA.
Equal Credit Opportunity Act (15 U.S.C. 1691) – Creditors are prohibited from discriminating against credit applicants on the basis of race, color, religion,
national origin, sex, marital status or age (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant’s
income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection
Act.
Debarment and Suspension Executive Order 12549 (2 C.F.R. Part 180 and Part 2700) – By submitting this loan application, you certify that neither
the Applicant or any owner of the Applicant have within the past three years been: (a) debarred, suspended, declared ineligible or voluntarily excluded from
participation in a transaction by any Federal Agency; (b) formally proposed for debarment, with a final determination still pending; (c) indicted, convicted,
or had a civil judgment rendered against you for any of the offenses listed in the regulations or (d) delinquent on any amounts owed to the U.S. Government
or its instrumentalities as of the date of execution of this certification.
6
SBA Form 2483-C (3/21)
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Paycheck Protection Program Borrower Application Form for Schedule (Lendistry)

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