Fillable Small Business Administration Community Advantage Application Business Information

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Small Business Administration Community Advantage Application Business Information

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Small Business Administration
Community Advantage Application
Date Established:
State:
Business Information
Entity Name:
Business Address:
City:
Business Type:
Contact Name:
Number of Current Employees:
Is your business a franchise?
Zip: County:
Federal Tax ID:
Phone Number: Email:
Number of jobs to be created as a result of this loan:
If yes, name the franchise:
Is your
business more than 51% woman or minority owned?
Required Documents
Please complete the application and send the items below. Your loan application will be reviewed once we
receive the completed, signed application and requested documents
below.
Small Business Applicant Ownership
Owner Name Title Ownership % Residential Address
SECTION I:
Applicant Business Information
Business Tax R
eturns (Prior
3 years)
Current YTD Business Financial Statements
Copy of Personal Guarantor/Principal Driver's License
Borrower Information Form
Business Plan
Professional Resume for Each Owner
Cash Flow
Projections (3 Years Preferred)
Personal Tax Returns (Prior 3 Years)
List all proprietors, partners, officers, directors, and holders of outstanding stock. 100% of ownership must be
reflected. Attach a separate sheet if necessary. Based on this form’s instructions not all owners will need to
complete the Principal Information section of this form.
Corporation
Business Need Amount Notes
Land
Buildings
Leasehold Improvements
Equipment
Furniture and Fixtures
Computers and Office Equipment
Vehicles
Other Capital Purchases
Working Capital (Cash)
Total Business Need
Summary of Business Applicant
Injection
Amount Notes
Personal Cash
Business Cash
Other Cash
Total Business Applicant Injection
Loan Amount
Insert total to fund the business start, expansion or purchase. Funds should be final and include the owner's
portion of funds, total loan amount and any investor funding. Any changes need to be sent to our program
immediate
ly.
Estimated Loan Need
$ 0.00
$ 0.00
$ 0.00
Description - Show
Manufacturer, Model,Serial
No.
Year
Acquired
Orginal
Cost
Market
Value
Amount of
Lien
Name of
Lienholder
Commercial Real Estate
Address
Year
Acquired
Orginal
Cost
Market
Value
Amount of
Lien Name of Lienholder
Name of C
reditor
Original
Amount
Cur
rent
Balance
Monthly
Payment
Amount
Current or
Delinquent Maturity Date
Business Debt Schedule
Unpaid Taxes (Describe in detail as to type, to whom payable, when due, amount, and what property, if any, a tax lien
List all Real Estate, Machinery and Equipment assets to be used as security for this loan.
All machinery and equipment greater than $5,000 must show; manufacturer or make, model, year, and serial
number. Items with no serial number must be clearly identified (use additional sheet if more space is
required.)
Collateral
Machinery and Equipment
$ 0.00
$ 0.00
$ 0.00
OMB APPROVAL NO.: 3245-0188
EXPIRATION DATE: 03/31/2021
SBA Form 413 (7a/504/SBG) (01-18) Previous Editions Obsolete Page 1
PERSONAL FINANCIAL STATEMENT
7(a) / 504 LOANS AND SURETY BONDS
U.S. SMALL BUSINESS ADMINISTRATION As of ________________, ________
SBA uses the information required by this Form 413 as one of a number of data sources in analyzing the repayment ability and creditworthiness of
an application for an SBA guaranteed 7(a) or 504 loan or, with respect to a surety bond, to assist in recovery in the event that the contractor
defaults on the contract. Submission of this information is required as part of your application for assistance. Failure to provide the information
would impact the agency’s decision on your application.
Complete this form for: (1) each proprietor; (2) general partner; (3) managing member of a limited liability company (LLC); (4) each owner of 20% or
more of the equity of the Applicant (including the assets of the owner’s spouse and any minor children); and (5) any person providing a guaranty on
the loan
Return completed form to:
For 7(a) loans: the Lender processing the application for SBA guaranty
For 504 loans: the Certified Development Company (CDC) processing the application for SBA guaranty
For Surety Bonds: the Surety Company or Agent processing the application for surety bond guarantee
Name Business Phone
Home Address Home Phone
City, State, & Zip Code
Business Name of Applicant
ASSETS (Omit Cents)
Cash on Hand & in banks…………………………$ ________________
Savings Accounts…………………………………..$ ________________
IRA or Other Retirement Account………………...$ ________________
(Describe in Section 5)
Accounts & Notes Receivable…………………….$ ________________
(Describe in Section 5)
Life Insurance – Cash Surrender Value Only……$ ________________
(Describe in Section 8)
Stocks and Bonds…………………………………..$ ________________
(Describe in Section 3)
Real Estate…………………………………………..$ ________________
(Describe in Section 4)
Automobiles…………………………………………$ ________________
(Describe in Section 5, and include
Year/Make/Model)
Other Personal Property……………………………$ ________________
(Describe in Section 5)
Other Assets………………………………………….$ _______________
(Describe in Section 5)
Total $ ________________
LIABILITIES (Omit Cents)
Accounts Payable……………………………$ ______________
Notes Payable to Banks and Others……….$ ______________
(Describe in Section 2)
Installment Account (Auto)…………………..$ ______________
Mo. Payments $ ___________
Installment Account (Other)………………....$ ______________
Mo. Payments $ ___________
Loan(s) Against Life Insurance……………...$ ______________
Mortgages on Real Estate…………………...$ ______________
(Describe in Section 4)
Unpaid Taxes………………………………….$ _____________
(Describe in Section 6)
Other Liabilities………………………………..$ _____________
(Describe in Section 7)
Total Liabilities………………………………....$ _____________
Net Worth……………………………………….$ _____________
Total $ _____________
*Must equal total in assets column.
Section 1. Source of Income.
Salary………………………………………………….$ ________________
Net Investment Income……………………………...$ ________________
Real Estate Income………………………………….$ ________________
Other Income (Describe below)*…………………...$ ________________
*Alimony or child support payments should not be disclosed in “Other Income” unless it is desired to have such payments counted toward total income.
Contingent Liabilities
As Endorser or Co-Maker…………………….$ _____________
Legal Claims & Judgments…………………..$ _____________
Provision for Federal Income Tax…………....$_____________
Other Special Debt…………………………….$ _____________
Description of Other Income in Section 1.
SBA Form 413 (7a/504/SBG) (01-18) Previous Editions Obsolete Page 2 of 6
Section 2. Notes Payable to Banks and Others. (Use attachments if necessary. Each attachment must be identified as part of this statement and signed.)
Names and Addresses of
Noteholder(s)
Original
Balance
Current
Balance
Payment
Amount
Frequency
(monthly, etc.)
How Secured or Endorsed
Type of Collateral
Section 3. Stocks and Bonds. (Use attachments if necessary. Each attachment must be identified as part of this statement and signed.)
Number of Shares Name of Securities Cost
Market Value
Quotation/Exchange
Date of
Quotation/Exchange
Total Value
Section 4. Real Estate Owned. (List each parcel separately. Use attachment if necessary. Each attachment must be identified as a part of this statement
and signed.)
Property A Property B Property C
Type of Real Estate (e.g.
Primary Residence, Other
Residence, Rental Property,
Land, etc.)
Address
Date Purchased
Original Cost
Present Market Value
Name & Address of
Mortgage Holder
Mortgage Account Number
Mortgage Balance
Amount of Payment per
Month/Year
Status of Mortgage
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.)
SBA Form 413 (7a/504/SBG) (01-18) Previous Editions Obsolete Page 3 of 6
Section 7. Other Liabilities. (Describe in detail.)
Section 8. Life Insurance Held. (Give face amount and cash surrender value of policies – name of insurance company and
Beneficiaries.)
I authorize the SBA/Lender/Surety Company to make inquiries as necessary to verify the accuracy of the statements made and to
determine my creditworthiness.
CERTIFICATION: (to be completed by each person submitting the information requested on this form and the spouse of any 20% or
more owner when spousal assets are included)
By signing this form, I certify under penalty of criminal prosecution that all information on this form and any additional supporting
information submitted with this form is true and complete to the best of my knowledge. I understand that SBA or its participating
Lenders or Certified Development Companies or Surety Companies will rely on this information when making decisions regarding an
application for a loan or a surety bond. I further certify that I have read the attached statements required by law and executive order.
Si
gnature ________________________________________ Date ____________________
Pr
int Name _______________________________________ Social Security No. ____________________
Si
gnature ________________________________________ Date ____________________
Pr
int Name _______________________________________ Social Security No. ____________________
NOT
ICE TO LOAN AND SURETY BOND APPLICANTS: CRIMINAL PENALITIES AND ADMINISTRATIVE REMEDIES FOR
FALSE STATEMENTS:
Knowingly making a false statement on this form is a violation of Federal law and could result in criminal prosecution, significant civil
penalties, and a denial of your loan or surety bond application. A false statement is punishable 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, a false statement is punishable
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. Additionally, false
statements can lead to treble damages and civil penalties under the False Claims Act, 31 U.S.C. § 3729, and other administrative
remedies including suspension and debarment.
PLEASE NOTE: According to the Paperwork Reduction Act, you are not required to respond to this request for information unless it displays a valid OMB
Control Number. The estimated average burden hours for the completion of this form is 1.5 hours per response. If you have questions or
comments concerning this estimate or any other aspect of this information collection, please contact: Director, Records Management
Division, Small Business Administration, 409 Third Street SW, Washington, D.C. 20416, and SBA Desk Officer, Office of Management and
Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503. PLEASE DO NOT SEND COMPLETED FORMS TO OMB.
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SBA Form 413 (7a/504/SBG) (01-18) Previous Editions Obsolete Page 4 of 6
PLEASE READ, DETACH, AND RETAIN FOR YOUR RECORDS
STATEMENTS REQUIRED BY LAW AND EXECUTIVE ORDER
SBA is required to withhold or limit financial assistance, to impose special conditions on approved loans, to provide
special notices to applicants or borrowers and to require special reports and data from borrowers in order to comply with
legislation passed by the Congress and Executive Orders issued by the President and by the provisions of various inter-
agency agreements. SBA has issued regulations and procedures that implement these laws and executive orders. These are
contained in Parts 112, 113, and 117 of Title 13 of the Code of Federal Regulations and in Standard Operating
Procedures.
Privacy Act (5 U.S.C. 552a)
Any person can request to see or get copies of any personal information that SBA has in his or her file when that file is
retrieved by individual identifiers such as name or social security numbers. 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.
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. Disclosures of name
and other personal identifiers are, however, required for a benefit, as SBA requires an individual seeking assistance from
SBA to provide it with sufficient information for it to make a character determination. In determining whether an
individual is of good 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 USC Section 636(a)(1)(B) of the Small Business Act ( the Act). Further, for all forms of assistance, SBA is
authorized to make all investigations necessary to ensure that a person has not engaged in acts that violate or will violate
the Act or the Small Business Investment Act, 15 USC Sections 634(b)(11) and 687(b)(a), respectively. For these
purposes, you are asked to voluntarily provide your social security number to assist SBA in making a character
determination and to distinguish you from other individuals with the same or similar name or other personal identifier.
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 investigative files 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 that SBA may disclose the information maintained in SBA’s investigative files to other Federal agencies conducting
background checks to the extent the information is relevant to the requesting agencies' function. In addition, another
routine use is that SBA may transfer information related to a debt that a person is delinquent in paying to SBA in
connection with its loan programs for publication on a computer database system maintained by the Department of
Housing and Urban Development, or other Federal agency, to allow searches by participating Government agencies and
approved private lenders, consistent with applicable law. SBA and its authorized lenders may also use this computer
database system to perform a computer match to determine a loan applicant’s credit status with participating agencies of
the Federal Government. See Revision of Privacy Act System of Records, 74 F.R. 14890 (April 1, 2009) and 77 F.R.
61467 (October 9, 2012) for additional background and other routine uses, which may be amended from time to time.
Right to Financial Privacy Act of 1978 (12 U.S.C. 3401) -- This is notice to you as required by the Right to Financial
Privacy Act of 1978, of SBA's 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. The law
provides that SBA shall have a right of access to your financial records in connection with its consideration or
administration of assistance to you in the form of a Government guaranteed loan. SBA is required to 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, after which no further certification is required for subsequent accesses. The law also provides that SBA's access
rights continue for the term of any approved loan guaranty agreement. No further notice to you of SBA's access rights is
required during the term of any such agreement. The law also authorizes SBA to transfer to another Government authority
any financial records included in an application for a loan, or 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 will be automatically 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 (and their officers, directors, stockholders or partners), the collateral pledged to secure the loan,
the amount of the loan, its purpose in general terms and the maturity. 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.
SBA Form 413 (7a/504/SBG) (01-18) Previous Editions Obsolete Page 5 of 6
Flood Disaster Protection Act (42 U.S.C. 4011) -- Regulations have been issued by the Federal Insurance
Administration (FIA) and by SBA implementing this Act and its amendments. These regulations prohibit SBA from
making certain loans in an FIA designated floodplain unless Federal Flood insurance is purchased as a condition of the
loan. Failure to maintain the required level of flood insurance makes the applicant ineligible for any financial assistance
from SBA, including disaster assistance.
Executive Orders -- Floodplain Management and Wetland Protection (42 F.R. 26951 and 42 F.R. 26961) – SBA
discourages settlement in or development of a floodplain or a wetland. This statement is to notify all SBA loan applicants
that such actions are hazardous to both life and property and should be avoided. The additional cost of flood preventive
construction must be considered in addition to the possible loss of all assets and investments due to a future flood.
Occupational Safety and Health Act (15 U.S.C. 651 et seq.) -- This legislation authorizes the Occupational Safety and
Health Administration in the Department of Labor to require businesses to modify facilities and procedures to protect
employees or pay penalty fees. Businesses can be forced to cease operations or be prevented from starting operations in a
new facility. Therefore, SBA may require additional information from an applicant to determine whether the business will
be in compliance with OSHA regulations and allowed to operate its facility after the loan is approved and disbursed.
Signing this form as an applicant is certification that the OSHA requirements that apply to the applicant business have
been determined and that the applicant, to the best of its knowledge, is in compliance. Furthermore, applicant certifies that
it will remain in compliance during the life of the loan.
Civil Rights Legislation -- 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. This includes making their goods and services available to handicapped
clients or customers. All business borrowers will be required to display the "Equal Employment Opportunity Poster"
prescribed by SBA.
Equal Credit Opportunity Act (15 U.S.C. 1691) -- The Federal Equal Credit Opportunity Act prohibits creditors 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.
Executive Order 11738 -- Environmental Protection (38 F.R. 251621) -- The Executive Order charges SBA with
administering its loan programs in a manner that will result in effective enforcement of the Clean Air Act, the Federal
Water Pollution Act and other environment protection legislation.
Debt Collection Act of 1982, Deficit Reduction Act of 1984 (31 U.S.C. 3701 et seq. and other titles) -- These laws
require SBA to collect aggressively any loan payments which become delinquent. 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 take one or more of the following actions: (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 other attorneys for litigation, (6) foreclose on collateral or take other action permitted in the loan
instruments, or (7) if you default on an SBA loan and fail to fully reimburse SBA for any resulting loss, refer you to the
computer database of delinquent Federal debtors maintained by the Department of Housing and Urban Development, or
other Federal agency, which may disqualify you from receiving financial assistance from other Federal agencies. In
addition, unless SBA is reimbursed in full for the loss, you will not be eligible for additional SBA financial assistance.
Immigration Reform and Control Act of 1986 (Pub. L. 99-603) -- If you are an alien who was in this country illegally
since before January 1, 1982, you may have been granted lawful temporary resident status by the United States
Immigration and Naturalization Service pursuant to the Immigration Reform and Control Act of 1986. For five years from
the date you are granted such status, you are not eligible for financial assistance from the SBA in the form of a loan
guaranty under Section 7(a) of the Small Business Act unless you are disabled or a Cuban or Haitian entrant. When you
sign this document, you are making the certification that the Immigration Reform and Control Act of 1986 does not apply
to you, or if it does apply, more than five years have elapsed since you have been granted lawful temporary resident status
pursuant to such 1986 legislation.
Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4821 et seq.) -- Borrowers using SBA funds for the
construction or rehabilitation of a residential structure are prohibited from using lead-based paint (as defined in SBA
regulations) on all interior surfaces, whether accessible or not, and exterior surfaces, such as stairs, decks, porches,
railings, windows and doors, which are readily accessible to children under 7 years of age. A "residential structure" is any
home, apartment, hotel, motel, orphanage, boarding school, dormitory, day care center, extended care facility, college or
other school housing, hospital, group practice or community facility and all other residential or institutional structures
where persons reside.
SBA Form 413 (7a/504/SBG) (01-18) Previous Editions Obsolete Page 6 of 6
Executive Order 12549, Debarment and Suspension (2 CFR 180, adopted by reference in 2 CFR Part 2700 (SBA
Debarment Regulations))
-- By submission of this loan application, you certify and acknowledge that neither you nor
any Principals have within the past three years been: (a) debarred, suspended, declared ineligible from participating in, or
voluntarily excluded from participation in a transaction by any Federal department or 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 due and owing to the U.S. Government
or its agencies or instrumentalities as of the date of execution of this certification.
If you are unable to certify and acknowledge (a) through (d), you must obtain and attach a written statement of exception
from SBA permitting participation in this loan. You further certify that you have not and will not knowingly enter into
any agreement in connection with the goods and/or services purchased with the proceeds of this loan with any individual
or entity that has been debarred, suspended, declared ineligible from participating in, or voluntarily excluded from
participation in a Transaction. All capitalized terms have the meanings set forth in 2 C.F.R. Part 180.
14
SBA Community Advantage Loan Application
Authorization and Indemnification Agreement
I/we hereby authorize South Central Kansas Economic Development District (hereafter referred to SCKEDD) or any of its
affiliates to make all inquiries it deems necessary to verify the accuracy of the information provided herein, to release any information
they may require at any time for any purpose related to my/our credit transaction with them, and to determine my/our credit
worthiness, including obtaining a credit report on me/us through the credit reporting agency of its choice, as well as to answer
questions others may ask about me/our record with SCKEDD. I/We understand that I/we must update credit and financial information
as requested if my/our financial condition changes. I/we hereby certify that the application information, including any
attachments and exhibits, are valid and correct to the best of my/our knowledge.
I/we hereby authorize the SCKEDD to furnish relevant information to all necessary sources including various federal,
state, county, and conventional funding opportunities to obtain the best sources for the project. I/we hereby authorize the
SCKEDD to furnish relevant information to SCKEDD’s Loan Committee and Board of Directors for decision; and, to furnish relevant
information to the various federal, state, and county agencies, officials and economic development representatives for
SCKEDD’s reporting requirements regarding area economic development.
I/we authorize any company, partnership, corporation, organization or entity of whatever kind to provide the SCKEDD with
any credit, financial or personal information held by such entity and requested by the SCKEDD.
I/we further agree that I shall indemnify and hold the SCKEDD harmless from any claim or cause of action arising because of
incorrect, inaccurate or incomplete information furnished by me, whether the furnishing of such incorrect, inaccurate or
incomplete information was accidental or intentional and in consideration of the SCKEDD’s assistance, I waive all claims against the
SCKEDD, its personnel or counselors arising from this assistance.
The small business applicant and its principals as individuals, agree to indemnify and hold SCKEDD and/or its agents
and assigns harmless from and against, any damages, cost, liability or expense attributable to release, threatened release,
discharge, manufacture, production, storage or disposal or the presence of hazardous toxic substances, on or under borrower’s
property or property in which borrower has an interest including adjoining real property and based upon claims assertble by
local, state, and federal governmental authority or other third parties against SCKEDD or its assigns.
This indemnification will specifically survive, and is entirely independent of the debtor’s contractual obligation to repay
the primary obligation held by SCKEDD as amended, extended, or renewed by SCKEDD, prepayment in full of the borrower’s
indebtedness to SCKEDD; and release of SCKEDD liens on borrower’s real or personal property by payment, foreclosure, or other
action including SCKEDD’s discretionary abandonment of lien.
Date ________________
Date ________________
Date ________________
All borrowers and guarantors must sign.
Signature ___________________________________________
Signature ___________________________________________
Signature ___________________________________________
Signature ___________________________________________
Date ________________
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Small Business Administration Community Advantage Application Business Information

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Completed 9 May 2021

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