SBA Form 2484 (Revised 1/21) 2
E. General Eligibility (If the answer is no to any, the loan cannot be approved)
The Applicant has certified to the Lender that (1) it 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; (2) current economic uncertainty makes this loan request necessary to support the ongoing operations of the
Applicant; (3) 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; and (4) 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)).
Yes No
The Applicant has certified to the Lender that 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, meets the size standard in number of employees established by the 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.
Yes No
The Applicant has certified to the Lender that (1) it has not and will not receive a Shuttered Venue Operator grant from
SBA; (2) 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; and (3) 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.
Yes No
F. Applicant Certification of Eligibility (If not true, the loan cannot be approved)
• The Applicant has certified to the Lender that the Applicant is eligible under the Paycheck Protection Program Rules.
G. Franchise/License/Jobber/Membership or Similar Agreement (If a franchise and not listed in the SBA Franchise Directory, the loan
cannot be approved)
The Applicant has represented to the Lender that it is a franchise.
• The Applicant has represented that the franchise is listed in SBA’s Franchise Directory.
• If Yes, enter the SBA Franchise Identifier Code here: _______________
Yes No
H. Character Determination (If no, the loan cannot be approved)
The Applicant has represented to the Lender that neither the Applicant (if an individual) nor any individual owning 20% or
more of the equity of the Applicant is 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.
Yes No
The Applicant has represented to the Lender that neither the Applicant (if an individual) nor any individual owning 20% or
more of the equity of the Applicant has 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, or within the last year for any other
felony: 1) been convicted; 2) pleaded guilty; 3) pleaded nolo contendere; or 4) commenced any form of parole or probation
(including probation before judgment).
Yes No
I. Prior Loss to Government/Delinquent Federal Debt (If no, the loan cannot be approved)
The Applicant has certified to the Lender that neither the Applicant nor any owner is 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.
Yes No
The Applicant has certified to the Lender that neither the Applicant nor any of its owners, nor any business owned or
controlled by any of them, ever obtained a direct or guaranteed loan from SBA or any other Federal agency that is (a)
currently delinquent, or (b) has defaulted in the last 7 years and caused a loss to the government.
Yes No
J. U.S. Employees (If no, the loan cannot be approved)
The Applicant has certified that the principal place of residence for all employees included in the Applicant’s payroll
calculation is the United States.
Yes No
K. Fees (If yes, Lender may not pass any agent fee through to the Applicant or offset or pay the fee with the proceeds of this loan)
Has the Lender directly contracted with a third party to assist in the preparation of the loan application or application
materials, or to perform other services in connection with this loan?
Yes No
