Fee Disclosure and Compensation Agreement OMB Control No. 3245-0201
For use with 7(a) and 504 Loan Programs Expiration Date: 08/31/2021
SBA Form 159 (04-18) Previous Editions Obsolete Page 3 of 3
Agent’s Certifications: By signing this form, the undersigned Agent certifies that: (1) it has not and will not directly or indirectly
charge or receive any payment from the Applicant in connection with the application for or making of the SBA loan except for
services actually performed on the Applicant’s behalf and identified in this form; (2) the information provided in this form accurately
describes the types of services (s)he/it has provided to the Applicant or SBA Lender and the compensation described in this form is
the only compensation that has been charged to or received from the Applicant or SBA Lender or that will be charged to the
aforementioned parties for services covered by this form; (3) neither it nor any of the employees of its organization are currently
debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from participation in this transaction by any
Federal department or Agency; and (4) if SBA deems any portion or all of the fees charged in connection with the application for or
making of the loan to be unreasonable or prohibited, the Agent agrees to refund that amount to the Applicant. If the certification is
made by a legal entity (e.g. corporation, limited liability company), execution of the certification must be in the legal entity’s name by
a duly authorized officer or other entity representative; if by a partnership, execution of the certification must be in the
partnership’s name by a general partner.
_________________________________________________
Signature of Authorized Representative of Agent
_____________________
Date
_________________________________________________
Print Name
________________________________________________
Title
SBA Lender’s Certifications: The undersigned SBA Lender certifies that: (1) the representations of services rendered and the
amounts charged as identified in this form are reasonable and satisfactory to it; (2) (s)he has no knowledge that any Agent, as defined
in 13 CFR § 103.1, was engaged by, represented, or worked on behalf of the Applicant other than as disclosed above or in another
executed compensation agreement (SBA Form 159); (3) any referral fees described above are the only referral fees paid by the SBA
Lender to a referral agent in connection with this loan and were not charged directly or indirectly to the Applicant; (4) if SBA deems
any portion or all of the fees charged in connection with the application for or making of the loan to be unreasonable or prohibited, the
SBA Lender agrees to refund that amount to the Applicant; (5) it has consulted the System for Awards Management’s (SAM)
Excluded Parties List System or any successor system to ensure that the Agent identified above is not debarred, suspended, proposed
for debarment, declared ineligible or voluntarily excluded from participation in this transaction by any Federal department or Agency;
and (6) any fee it has charged is not a standardized amount and all fees charged to the Applicant comply with SBA Loan Program
Requirements.
_________________________________________________
Signature of Authorized Representative of SBA Lender
_____________________
Date
_________________________________________________
Print Name
_________________________________________________
Title
Systems of Record Notification: Information obtained from this form is part of the Agency’s Privacy Act Systems of Records, Loan
Systems (“SOR 21”) and may become part of SBA’s System of Records for Suspension and Debarment Files (“SOR 36”). As such,
this form and the information contained therein may be used, disclosed, or referred for the following purposes, among other things:
• To the Federal, State, local or foreign agency or professional organization which investigates, prosecutes, or enforces violations
of statutes, rules, regulations, or orders, or which undertakes procurement of goods or services, when SBA determines that
disclosure will promote programmatic integrity or protect the public interest.
• To SBA employees, contractors, interns, volunteers, and other regulators or legal authorities for the review of Loan Agent fees
and activities and for the review of loans generated by Loan Agents (e.g. for performance and other trends).
• To GSA and the public for publication of Loan Agent suspensions, revocations, debarments, other enforcement actions, and
exclusions in the System Award’s Management’s (SAM) Excluded Parties List System (“EPLS”) or any successor system
consistent with Executive Order 12549 and other applicable law.
• To other regulators, SBA employees, contractors, interns, and/or volunteers for regulatory purposes.
• See 77 FR 61467 (October 9, 2012), 77 FR 15835 (March 16, 2012), 74 FR 14890 (April 1, 2009), and as amended from time-
to-time for additional routine uses.
PLEASE NOTE: The estimated burden for completion of this form is 5 minutes per response. You are not required to respond to this
information collection unless it displays a currently valid OMB approval number. Comments/questions on the burden estimate should
be sent to U.S. SBA, Chief, Administration Information Branch, Washington, D.C. 201416, and Desk Officer for SBA, OMB, New
Exec. Office Building, Room 10202, Washington, D.C. 20503. PLEASE DO NOT SEND FORMS TO THESE ADDRESSES.
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