Fillable SBA form 2484 Paycheck Protection Program Lender Application Form

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SBA form 2484 Paycheck Protection Program Lender Application Form

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The SBA form 2484 Paycheck Protection Program Lender Application Form form is 2 pages long and contains:

  • 1 signature
  • 16 check-boxes
  • 39 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Department of the Treasury - OCIO

BROWSE DEPARTMENT OF THE TREASURY - OCIO (DC) FORMS

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Paycheck Protection Program
Lender Application Form - Paycheck Protection Program Loan Guaranty
SBA Form 2484 (Revised 04/20)
1
OMB Control No.: 3245-0407
Expiration Date: 09/30/2020
The purpose of this form is to collect identifying information about the Lender, the Applicant, the loan guaranty request, sources and uses of funds, the
proposed structure (which includes pricing and the loan term), and compliance with SBA Loan Program Requirements. This form reflects the data fields
that will be collected electronically from lenders; no paper version of this form is required or permitted to be submitted. As used in this application,
“Paycheck Protection Program Rule” refers to the rules in effect at the time you submit this application that have been issued by the Small Business
Administration (SBA) implementing the Paycheck Protection Program under Division A, Title I of the Coronavirus Aid, Relief, and Economic Security
Act (CARES Act).
Instructions for Lenders
All Paycheck Protection Program (PPP) loans are processed by all Lenders under delegated authority from SBA. This application must be submitted and
signed electronically in accordance with program requirements, and the information requested is to be retained in the Lender’s loan file.
A.
Lender Information
Lender Name: Lender Location ID:
Address: City: St: Zip:
Lender Contact: Ph: ( ) - Cell or Ext: ( ) -
Contact Email: Title:
B. Applicant Information
Applicant
Check One: Sole Proprietor Partnership C-Corp S-Corp LLC Independent contractor
Eligible self-employed individual 501(c)(3) nonprofit 501(c)(19) veterans organization
Tribal business (sec. 31(b)(2)(C) of Small Business Act) Other
Applicant Legal Name: ____________________________
DBA: ____________________________ Business Tax ID:
___________________
Applicant Address: ____________________________ City, State, Zip:
____________________________
Applicant Primary Contact: Phone: ( ) -
C. Loan Structure Information
Amount of Loan Request: $ Guarantee %: 100% Loan Term in # of Months: 24 Payment: Deferred 6 mos.
Applicant must provide documentation to Lender supporting how the loan amount was calculated in accordance with the Paycheck Protection
Program Rule and the CARES Act, and Lender must retain all such supporting documentation in Lender’s file.
Interest Rate: 1%
D. Loan Amount Information
Average Monthly Payroll multiplied by 2.5 $
Refinance of Eligible Economic Injury Disaster Loan, net of Advance (if Applicable; see Paycheck
Protection Program Rule)
$
Total
$
E. General Eligibility (If the answer is no to either, the loan cannot be approved)
The Applicant has certified to the Lender that (1) it was in operation on February 15, 2020 and had employees for
whom the Applicant 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 mortgage interest payments,
lease payments, and utility payments, and (4) the Applicant has not received another Paycheck Protection Program
loan.
Yes
No
The Applicant has certified to the Lender that it (1) is an independent contractor, eligible self-employed individual,
or sole proprietor or (2) employs no more than the greater of 500 or 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.
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 Rule.
True
G. Franchise/License/Jobber/Membership or Similar Agreement (If applicable and no, the loan cannot be approved)
The Applicant has represented to the Lender that it is a franchise that is listed in the SBA’s Franchise Directory.
Yes
No
SBA Form 2484 (Revised 04/20) 2
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 subject to an indictment, criminal information, arraignment, or other
means by which formal criminal charges are brought in any jurisdiction, or is presently incarcerated, or on probation
or parole.
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: 1) been convicted; 2) pleaded
guilty; 3) pleaded nolo contendere; 4) been placed on pretrial diversion; or 5) been placed on 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 (as defined in the Applicant’s
SBA Form 2483) 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 currently delinquent or 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)
Is the Lender using 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
SBA Certification to Financial Institution under Right to Financial Privacy Act (12 U.S.C. 3401)
By signing SBA Form 2483, Borrower Information Form in connection with this application for an SBA-guaranteed loan, the Applicant certifies that it
has read the Statements Required by Law and Executive Orders, which is attached to Form 2483. As such, SBA certifies that it has complied with the
applicable provisions of the Right to Financial Privacy Act of 1978 (12 U.S.C. 3401) and, pursuant to that Act, no further certification is required for
subsequent access by SBA to financial records of the Applicant/Borrower during the term of the loan guaranty.
Lender Certification
On behalf of the Lender, I certify that:
The Lender has complied with the applicable lender obligations set forth in paragraphs 3.b(i)-(iii) of the Paycheck Protection Program Rule.
The Lender has obtained and reviewed the required application (including documents demonstrating qualifying payroll amounts) of the Applicant
and will retain copies of such documents in the Applicant’s loan file.
I certify that:
Neither the undersigned Authorized Lender Official, nor such individual’s spouse or children, has a financial interest in the Applicant.
Authorized Lender Official: Date:
Signature
Type or Print Name: Title:
NOTE: According to the 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 burden for completing this form, including time for reviewing instructions, gathering data needed, and
completing and reviewing the form is 25 minutes per response. Comments or questions on the burden estimates should be sent to U.S. 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, Rm. 10202, Washington DC 20503. PLEASE DO NOT SEND FORMS TO THESE
ADDRESSES.
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SBA form 2484 Paycheck Protection Program Lender Application Form

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Completed 11 April 2020

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