Rev. May 2017
The Missouri Small Business Disaster Relief
Loan Program
Guidelines and Application
June 2011
(Rev. May 2017)
Sponsored by:
The Missouri Department of Economic Development (DED) and
the Missouri Development Finance Board (MDFB)
Program Guidelines (Page 1 of 3)
Rev. May 2017
Small Business Disaster Relief Loan Program DED/MDFB
Loan Program Parameters:
1. The Disaster Relief loan program, part of the MO Small Business Loan Program, intends to
provide financial assistance and access to capital to businesses impacted by a natural disaster.
This may include businesses sustaining direct property damage or local businesses sustaining
interruptions to their operation and services because of temporary customer loss, temporary
interference with access or other impacts;
2. The interest rate is 3 percent with a 2-year deferral period or 1 percent interest rate for the 10-year
term of the loan (borrower’s option);
3. The terms are typically 10 years or less but may be adjusted for adequate debt coverage. Loan
repayment is quarterly principal and interest payments;
4. Payments may be auto debited from a checking or savings account;
5. The minimum loan amount is $2,500 and the maximum loan amount is $50,000;
6. The number of loans per household will be limited to 1;
7. The company must be 100 percent Missouri owned and 100 percent Missouri located;
8. The company must be registered with the Secretary of State in good standing;
9. The company may not be a gambling entity, a check cashing service (unless associated with a
bank), a pawn broker service, resale of donated or used goods, liquidation sales, day labor
services, job training services, sale or distribution of alcohol or tobacco products, web based or
print newspapers or magazines, speculative real estate, radio or television stations. The owner
may not be employed by the State of Missouri;
10. Loan proceeds may be used for working capital, inventory, equipment purchase, real property
improvements (owned by borrower) but cannot be used for refinancing of existing debt or
outstanding debt payments (see funding guidelines below);
11. Loan proceeds must begin to be drawn within 60 days of the loan approval date and all loan
proceeds drawn within 1 year of the approval date [unless authorized additional time by Missouri
Department of Economic Development (DED) and Missouri Development Finance Board
(MDFB)]. Failure to draw funds within this time line will result in requiring the resubmission of
an amended application and an additional credit review. This loan is not a line of credit;
12. Loan origination, collateralization, and loan servicing may be provided by an entity contracted by
the MDFB;
13. Determination of loan delinquency and default is made by the MDFB. Late payment fees may be
14. The company must provide a certificate of insurance naming MDFB as an additional insured on
their business insurance each time a policy is renewed;
15. Loan collections will be referred to the Financial Services Division of the Missouri Attorney
General’s Office.
Program Guidelines (Page 2 of 3)
Rev. May 2017
Loan Funding Guidelines:
1. Acceptable working capital expenses include the below expenses:
General Liability Insurance, Property Insurance, and Workers Compensation;*
Health Insurance;*
Leases/Rent (a copy of the lease is required);*
Contractors (need contract and billing for services);
Telephone, Internet, utilities; *
Supplies. *
*Expenses incurred within three (3) months prior to approval of the application qualify with
acceptable documentation evidencing incurrence or payment of these expenses.
2. Acceptable equipment expenses include:
Paid for equipment (may be reimbursed if purchased within the previous 3 month
Unpaid for equipment (a bid/quote or invoice is required to be reimbursable and a check
will be made to vendor and loan applicant).
Loan Application Instructions:
1. Loan applications must be made on the form attached.
2. One (1) original signed copy shall be postmarked or delivered to:
Missouri Department of Economic Development
Small Business Loan Program
301 West High Street, Suite 770, P.O. Box 118
Jefferson City, Missouri 65102
3. Loan applications must be complete with all questions answered; applications not in compliance
with steps 1-3 may be considered non-responsive.
4. Applicants approved will be required to complete additional loan paperwork, including the
payment of any reasonable processing fees, prior to accessing the loan funds.
5. Applicants must complete the Certification and Affirmation on pages 11 and 12 of the
6. Applicants must complete and submit Form 943 to obtain a tax clearance certificate (valid for 60
days) from the Missouri Department of Revenue. Form 943 is at
7. Applicants must be enrolled in E-Verify and submit an electronically signed Memorandum of
Understanding. Find more information and enroll at
Program Guidelines (Page 3 of 3)
Rev. May 2017
Loan Application Checklist:
o One complete, original signed, and dated application submitted to DED
o One complete copy (keep for company file) for the applicant’s own records and file
o Missouri Department of Revenue Tax Clearance Certificate (see Item 6 Loan Application
o Memorandum of Understanding from E-Verify (see Item 7 Loan Application
o Signed and Notarized Certification and Affirmation page
o A $15 nonrefundable check or money order made out to the Missouri Development
Finance Board (for credit reviews)
Application (Page 1 of 12)
Rev. May 2017
DED/MDFB Small Business Disaster
Relief Loan Application
All applicants must read and follow the Guidelines section of this Application. The Guidelines section contains
information on the Loan Program Parameters, the Loan Applications Instructions, and a Loan Application Checklist.
Date of Birth
Home Telephone Business Telephone
Fax E-mail
Business Name
Federal ID Number
How was the business affected by the disaster?
Any personal/business judgments, unsettled lawsuits or major disputes? Yes_____ No_____
If yes, please explain.
Has the business, or any principals, been involved in bankruptcy or insolvency proceedings? Yes____
If yes, please explain.
Is the business insured? Yes_____ No_____ If so, for how much? $____________
No_____ Not at this time_____Has the business applied for Federal Disaster assistance?
If so, for how much?$____________
Yes_____ No_____ Not at this time_____
Has the business applied for Small Business Administration assistance?
If so, for how much? $____________
Has the business suffered direct losses as a result of the disaster? Yes_____ No_____
Has the business been able to resume regular business activities since the disaster? Yes_____ No_____
What date was the business interrupted due to the disaster?
Application (Page 2 of 12)
Rev. May 2017
Purpose of loan request
Working capital $ Equipment $
Inventory $ Leasehold improvements $
Personal (not borrowed) funds available to invest in business $
Other Sources of Funds
Have you contacted your bank for financing? Yes ___ No ___ What bank?
Who referred you to the program? Phone
The MDFB has requested that we obtain the following information for statistical purposes only. Please check all
those that apply.
Business owned by _____(> 50% Female owned) _____(> 50% minority owned)
Veteran Status _____Non-Veteran _____Vietnam-era Veteran _____Other Veteran
Ethnicity: _____ African American _____White _____Hispanic _____Asian/Pacific
_____ Islander _____Eskimo/Aleuts _____American Indian _____Multi Ethnic
What is your combined yearly household income as of today? $
How many are in your household?
Please provide the following items with a completed application and forms.
Copies of business tax returns for the previous 3 years.
Copies of personal tax returns for the previous 3 years.
Aging of Accounts Receivable and Accounts Payable (if applicable).
Check for $15 made payable to MDFB for a credit review.
Please read the following and sign the Application Form. All owners, officers, and partners must sign this
The information in this Loan Application is provided for the purpose of applying for funds under the DED/MDFB
Small Business Disaster Relief Loan Program. The information is accurate to the best of my knowledge. I
understand that personal and/or business information may be requested pursuant to this loan application and I hereby
give my consent for such information to be provided to DED. I also understand that DED/MDFB retains the sole
decision as to whether this loan application is approved, disapproved, or modified. It is my right to accept or decline
the loan amount, rate and terms approved by DED/MDFB.
I AUTHORIZE DED/MDFB to keep this application whether or not my request for credit is approved. By signing
below, I authorize DED to obtain a credit report on me through the credit-reporting agency of its choice, as well as
to answer questions others may ask about my credit record with DED/MDFB (if applicable). I understand that I must
provide updated credit and financial information as requested if my financial condition changes.
Total amount of loan request (maximum $50.000) $_________________
Application (Page 3 of 12)
Rev. May 2017
This loan program is part of the State of Missouri’s disaster recovery efforts. During periods of
disaster recovery, the Missouri Department of Economic Development (DED) maintains a
working partnership with the Small Business Administration (SBA) for the purpose of business
referral, education and other cooperative efforts that ensure businesses have every opportunity
to access capital necessary for a full recovery. DED and SBA also make every effort to avoid
any duplication of benefits provided through federal and state disaster assistance to any one
business entity. DED and SBA operate under a formal Memorandum of Understanding that
maintains and protects business and personal information subject to applicable privacy laws. As
the business owner or authorized representative I understand and agree that as an applicant for
business recovery funding, the DED and SBA will share any and all information provided in the
application(s) between and among their respective agencies as allowed under law.
Print Name
Signature Date
Print Name
Signature Date
MDFB is an Equal Opportunity lender. DED will not discriminate against any loan applicant because of his or her race, color, religion, sex,
handicap, familial status, or national origin.
Application (Page 4 of 12)
Rev. May 2017
As of , 20
Complete this form for: (1) each proprietor, or (2) each limited partner who owns 20% or more interest and each general partner, or
(3) each stockholder owning 20% or more of voting stock and each corporate officer and director, or (4) any other person or entity providing a guaranty on the loan.
Name: ____________________________________________________________________________________________________
(Omit cents)
Cash on Hand and in Banks
Accounts Payable
Savings Accounts
Notes Payable to Banks and Others
(Describe in Section 2)
IRA or Other Retirement Accounts
Unpaid Taxes
(Describe in Section 6)
Accounts and Notes Receivable
Installment Account (Other)
Mo. Payments $
Life Insurance Cash Surrender Value Only
(Complete Section 8)
Loan on Life Insurance
Stocks and Bonds
(Describe in Section 3)
Line of Credit tied to Real Estate
Real Estate
(Describe in Section 4)
Mortgages on Real Estate
(Describe in Section 4)
Automobile Present Value
Installment Account (Auto)
Mo. Payments $
Other Personal Property
(Describe in Section 5)
Other Liabilities
(Describe in Section 7)
Other Assets (Describe in Section 5)
Total Assets
Total Liabilities
Net Worth
SECTION 1. Source of Income
Contingent Liabilities
As Endorser or Co-Maker
Net Investment Income
Legal Claims and Judgments
Real Estate Income
Provision for Federal Income Tax
Other Income (Describe below)*
Other Special Debt
Description of Other Income in Section 1. Please describe any recurring income not reflected on previous tax returns:
*Alimony or child support payments need not be disclosed in “Other Income” unless it is desired to have such payments counted toward total income.
SECTION 2. Notes Payable to Bank and Others (Use attachments if necessary. Each attachment must be identified as a part of this statement and
Name and Address of Note Holder(s)
Original Balance
Current Balance
Payment Amount
(monthly, etc.)
How Secured or Endorsed
Type of Collateral
Application (Page 5 of 12)
Rev. May 2017
Number of Shares Number of Securities Cost Market Value
Quotation Exchange
Date of
Total Value
SECTION 4. Real Estate (List each parcel separately. Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.)
Property A Property B Property C
Type of Property
Address of Property
Name of Property Owner
Date Purchased
Original Cost
Present Market Value
Name of Lender
Loan Number
Loan Balance
Amount of Payment per Month
Status of Loan
SECTION 5. Other Personal Property and Other Assets (Describe, and if any is pledged as security, state name and address of lien holder, amount of
lien, terms of payment, and if delinquent, describe delinquency.)
SECTION 6. Unpaid Taxes (Describe in detail as to type, to whom payable, when due, amount, and to what property, if any, a tax lien attaches.)
SECTION 7. Other Liabilities (Describe in detail.)
SECTION 8. Insurance Held (Give face amount and cash surrender value of policies name of insurance and beneficiaries.)
I authorize Lender to make inquiries as necessary to verify the accuracy of the statements made and to determine my creditworthiness. I certify the above and the
statements contained in the attachments are true and accurate as of the stated date(s). These statements are made for the purpose of either obtaining a loan or guaranteeing
a loan. I understand FALSE statements on a Missouri Small Business Loan application may subject me to the penalties prescribed by section 570.140, RSMo. FALSE
ments on a conventional loan application may result in fines and imprisonment under relevant Federal and State laws.
Signature:_____________________________________________________ Date: ______________ Social Sec. No.: _________________
Signature: _____________________________________________________ Date: _______________ Social Sec. No.: _________________
SECTION 3. Stocks and Bonds (
Use attachments if necessary. Each attachment must be identified as a part of this statement and
Application (Page 6 of 12)
Rev. May 2017
Serial #
Purchase Item
Existing Item
Value $
Application (Page 7 of 12)
Rev. May 2017
Year Ending
Gross Sales
Less Returns & Allowances
Net Sales
Cost of Sales
Gross Profit
Operating Expenses
Salaries & Wages
Payroll Taxes
Total Selling Expenses
General & Administrative
Salaries & Wages
Payroll Taxes
Employee Benefits
Automobile Expense
Dues & Subscriptions
Legal & Accounting
Office Supplies
Application (Page 8 of 12)
Rev. May 2017
Taxes & Licenses
Total General & Administrative
Total Operating Expenses
Operating Profit (Loss)
Other Income and Expenses
Net Income and Expenses
Net Income (Loss) Before Taxes
Income Taxes
Net Income (Loss)
Application (Page 9 of 12)
Rev. May 2017
Period Ending
Current Assets
Cash and Equivalents
Accounts Receivable
Prepaid Expenses
Total Current Assets
Fixed Assets
Less: Accumulated
Total Fixed Assets, Net
Other Assets
Total Assets
Liabilities and Shareholders’ Equity
Current Liabilities
Accounts Payable
Short-Term Debt
Current Portion of Long-Term Debt
Income Taxes Payable
Accrued Expenses
Total Current Liabilities
Long-Term Debt
Application (Page 10 of 12)
Rev. May 2017
Shareholders’ Equity
Capital Stock
Additional Paid-In Capital
Retained Earnings
Total Shareholders’ Equity
Total Liabilities and Shareholders’ Equity
Personal References (relative or close friend may be included)
Reference Name #1
City State ZIP
Phone E-mail
Reference Name #2
City State ZIP
Phone E-mail
Bank References
Bank Name #1 Account #
City State ZIP
Phone Contact
Bank Name #2 Account #
City State ZIP
Phone Contact
Internet Resources for Small Businesses
Application (Page 11 of 12)
Rev. May 2017
I certify that I am an authorized representative of the Applicant and as such am authorized to make the statement of
affirmation contained herein.
I certify that the Applicant does NOT knowingly employ any person who is an unauthorized alien and that the
applicant has complied with federal law (8 U.S.C. § 1324a) requiring the examination of an appropriate document
or documents to verify that each individual is not an unauthorized alien.
I certify that the Applicant is enrolled and will participate in a federal work authorization program as defined in
Section 285.525(6), RSMo, with respect to employees working in connection with the activities that qualify the
Applicant for the Missouri Small Business Loan Program. I certify that the Applicant will maintain and, upon
request, provide the Department of Economic Development documentation demonstrating the Applicant’s
participation in a federal work authorization program with respect to employees working in connection with the
activities that qualify the Applicant for this Program.
I understand that, pursuant to section 285.530.5, RSMo, a general contractor or subcontractor of any tier shall not
be liable under sections 285.525 to 285.550 when such general contractor or subcontractor contracts with its direct
subcontractor who violates section 285.530.1, if the contract binding the contractor and subcontractor affirmatively
states that the direct subcontractor is not knowingly in violation of section 285.530.1 and shall not henceforth be in
such violation and the contractor or subcontractor receives a sworn affidavit under the penalty of perjury attesting to
the fact that the direct subcontractor’s employees are lawfully present in the United States.
I understand that if the Applicant is found to have employed an unauthorized alien, the Applicant may be subject to
penalties pursuant to sections 135.815, 285.025, and 285.535, RSMo.
I hereby agree to allow representatives of the Department of Economic Development access to the property and
applicable records as may be necessary for the administration of the Missouri Small Business Loan Program.
I certify under penalties of perjury that the above statements and information contained in the application and
attachments are complete, true, and correct to the best of my knowledge and belief.
I attest the information submitted by the company to DED regarding the project is consistent with documents
provided to lenders, other governmental entities or investors who may provide funding for the project and that DED
is authorized to verify such information from any source.
For a privately held company, I agree to disclose any person who owns an ownership interest or who is employed in
a management capacity by the company who has committed a felony, is presently under indictment, or is on parole
or probation.
I attest there are no pending or threatened liens, judgments, or material litigation which is likely to affect the viability
of the company as an ongoing concern.
I certify the company does not have any delinquent non-protested federal, state or local taxes
I certify that neither the operations of the company nor the requested funding would violate any existing agreement.
I certify that the company has not filed (nor is about to file) for bankruptcy.
I certify the company has not failed to fulfill any obligations under any other state or federal program.
I certify the signatory is the authorized representative of the applicant and is authorized to make the statement of
affirmation contained therein.
Required Attachment:
Copy of the executed Memorandum of Understanding between the Applicant and the United States
Citizenship and Immigration Services (USCIS).
Name Title
Signature Date
Application (Page 12 of 12)
Rev. May 2017
) ss.
COUNTY OF____ _________________________ )
On this ______ day of ____________, 20___ before me, _______________________________________,
a Notary Public in ____________________________, and for said state, personally appeared
__________________________________, known to me to be the person who executed the Certification
and Affirmation and acknowledges and states on his/her oath to me that he/she executed the same for the
purposes therein stated.
Notary Public
My commission expires _______________________.