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SBA Form 1919 (Revised 09/20)
1
SBA 7a Borrower Information Form
OMB Control No.: 3245-0348
Expiration Date: 09/30/2023
For use with all 7(a) Programs
Purpose of this form:
The purpose of this form is to collect information about the Small Business Applicant ("Applicant") and its owners, the loan
request, existing indebtedness, information about current or previous government financing, and certain other topics. The
information also facilitates background checks as authorized by section 7(a)(1)(B) of the Small Business Act, 15 U.S.C.
636(a)(1)(B). Submission of the requested information is required for SBA or the Lender to determine eligibility for financial
assistance. Failure to submit the information would affect that determination.
Definitions:
1. Affiliation - Concerns and entities are affiliates of each other when one controls or has the power to control the
other, or a third party (or parties) controls or has power to control both. For example, affiliation may arise through
ownership, common management (including through a management agreement), or when there is an identity of interest
between close relatives with identical, or substantially identical, business interests. The complete definition of
"affiliation" is found at 13 CFR § 121.301(f).
2. Close Relative - Close Relative is a spouse; a parent; or a child or sibling, or the spouse of any such person.
3. Eligible Passive Company ("EPC") - is a small entity or trust which does not engage in regular and continuous
business activity which leases real or personal property to an Operating Company for use in the Operating Company's
business, and which complies with the conditions set forth in 13 CFR § 120.111.
4. Household Member - A "household member" of an SBA employee includes: a) the spouse of the SBA employee;
b) the minor children of said individual; and c) the blood relatives of the employee, and the blood relatives of the
employee's spouse who reside in the same place of abode as the employee. [13 CFR § 105.201(d)]
5. Operating Company ("OC") - is an eligible small business actively involved in conducting business operations
now or about to be located on real property owned by an Eligible Passive Company, or using or about to use in its
business operations personal property owned by an Eligible Passive Company.
For clarification regarding any of the questions or terms contained herein, please contact your Lender.
Instructions for completing this form:
This form is to be completed by the Applicant and all individuals identified
below and submitted to an SBA Participating Lender. This form is divided into three sections: Section I requests
information about the Small Business Applicant and must be completed in its entirety, signed and dated by an authorized
representative of the Small Business Applicant that is requesting a business loan. A separate Section I is required to be
completed and signed for each co-applicant (e.g. "Eligible Passive Company (EPC)" or "Operating Company (OC)").
Sections II and III of this form requests information about each of the Applicant's owners - Section II for individuals, Section
III for each entity owning an equity interest in the Applicant (e.g. Employee Stock Ownership Plan ("ESOP"), 401(k) plan,
Limited Liability Company, or other entity owner entities and trusts. A separate Section II and/or Section III is required to
be completed and signed by:
o For a sole proprietorship, the sole proprietor;
o For a partnership, all general partners, and all limited partners owning 20% or more of the equity of the firm;
or any partner that is involved in management of the applicant business;
o For a corporation, all owners of 20% or more of the corporation, and each officer and director;
o For limited liability companies, all members owning 20% or more of the company, each officer, director,
and managing member;
o Any person hired by the Applicant to manage day-to-day operations of the Applicant business ("key
employee"); and
o Any Trustor (if the Applicant is owned by a trust).
o Each entity owning an equity interest in the Applicant.
All parties listed above are considered "Associates" of the Small Business Applicant as defined in 13 CFR § 120.10. A separate
Section I (for the Applicant and each Co-Applicant), Section II (for individuals), and Section III (for entities) is required to be
completed and signed by each Associate of the Small Business Applicant.
SBA Form 1919 (Revised 09/20)
2
SBA 7(a) Borrower Information Form
OMB Control No.: 3245-0348
Expiration Date: 09/30/2023
(Section I: Business Information)
Applicant Business Legal Name
(
OC EPC
):
Operating Business Legal Name (OC):
DBA or Trade name, if applicable:
Is the Applicant a?:
Cooperative:
ESOP:
401(k) Plan: Trust: Other: N/A:
Do you plan to use a 401(K) Plan (including a Rollover for Business Start Up (ROBS) Plan) for equity?
Yes No
Will a Management Company be hired by the Applicant to manage the day-to-day operations?
(If yes, provide a copy of the management agreement)
Yes No
Primary Business Address
Business Tax ID
Primary Business Phone
Project Address (if other than primary business address)
Primary Contact Name
Email Address
Amount of Loan Request:
$
# of existing employees employed by business?
(including owners):
# of jobs to be created as a result of the loan? (including
owners):
# of jobs that will be retained as a result of the loan that otherwise would have been lost?
(including owners):
$
for:
$
for:
Purpose of the loan (i.e. Purchase
Real Estate; Construction;
Equipment; Inventory; Eligible
Debt Refinancing; Working
Capital; etc.):
$
for:
$
for:
$
for:
$
for:
If financial statements provided to the lender do not include a schedule of business debt, provide on a separate attachment.
Ownership of the Applicant
List all proprietors, partners, officers, directors, members, and holders of outstanding stock. 100% of ownership must be
reflected. Attach a separate sheet if necessary. Based on the instructions to this form not all owners will need to complete the
Associate's Information section of this form.
Owner's Legal Name Title %
Owned
TIN
(SSN/EIN)
AddressAddress ESOP* 401K* COOP*
If any owner(s) is an ESOP, a 401(k) plan, or a Cooperative, please provide details and relevant documentation to the Lender as
appropriate.
* Any Applicant owned in part, or in whole, by an ESOP or 401(k) plan must also provide to the Lender evidence that the
Applicant, ESOP or the 401(k) plan are in compliance with all applicable IRS, Treasury, and Department of Labor requirements
and it will comply with all relevant operating and reporting requirements.
SBA Form 1919 (Revised 09/20)
3
SBA 7(a) Borrower Information Form
(Section I: Business Information)
OMB Control No.: 3245-0348
Expiration Date: 09/30/2023
Unless stated otherwise, if any of the questions below are answered "Yes," please provide details on a separate sheet.
# Question Yes No
1
Are there co-applicants? (If "Yes," please complete a separate Section I: Applicant Business
Information for each.)
2
Has an application for the requested loan ever been submitted to the SBA, a lender, or a Certified
Development Company, in connection with any SBA program?
3
Has the Applicant and/or its Affiliates ever obtained or applied for a direct or guaranteed loan from
SBA, or another Federal agency loan program (including, but not limited to USDA, B&I, FSA, EDA),
or been a guarantor on such a loan? (if "Yes," answer questions 3.a) and 3.b) below.)
3 a) Is any of the financing currently delinquent?
3 b) Did any of this financing ever default and cause a loss to the Federal Government?
4
Is the Applicant presently suspended, debarred, proposed for debarment, declared ineligible, or
voluntarily excluded from participation in this transaction by any Federal department or agency?
5
Does the Applicant Business operate under a Franchise/License/Distributor/Membership/Dealer/
Jobber or other type of Agreement? (If "Yes," provide copies of your agreement(s) and any other
relevant documents.)
6
Does the Applicant have any Affiliates per 13 CFR 121.301? (If "Yes", attach a listing of all
Affiliates.)
7 Has the Applicant and/or its Affiliates ever filed for bankruptcy protection?
8 Is the Applicant and/or its Affiliates presently involved in any pending legal action?
9
Are any of the Applicant's products and/or services exported (directly or indirectly), is there a plan to
begin exporting (directly or indirectly) as a result of this loan, or is this an Export Working Capital
Program (EWCP)* loan? (If "Yes," answer questions 9.a) and 9.b) below.)
9
a) Provide the estimated total export sales this loan will support. $
9
* (For EWCP loans, in a separate attachment, provide details of the underlying transaction(s) for which the loan
is needed, countries where the buyers are located and a description of products and/or services to be exported.)
9 b) List of principal countries of export (list at least 1)
10
Has the Applicant paid or committed to pay a fee to the Lender or a third party to assist in the
preparation of the loan application or application materials, or has the Applicant paid or committed to
pay a referral agent or broker a fee?
11
Are any of the Applicant's revenues derived from gambling, loan packaging, or from the sale of
products or services, or the presentation of any depiction, displays or live performances, of a prurient
sexual nature? If "Yes," provide details under a separate attachment.
SBA Form 1919 (Revised 09/20)
4
SBA 7(a) Borrower Information Form
(Section I: Business Information)
OMB Control No.: 3245-0348
Expiration Date: 09/30/2023
SBA may not provide financial assistance to an applicant where there is any appearance of a conflict of interest with an
SBA or other Federal government employee. If any of the questions below are answered "Yes," please provide details on
a separate sheet.
With the exception of question 15, if any of the questions below are answered "Yes," this application may not be
submitted under any delegated processing method, but must be submitted by the Lender under non-delegated
processing. Note: This does not mean that your loan will be denied, only that your Lender will need to use different
SBA procedures to process this loan. If the answer to question 15 is "Yes," the application may be processed under a
lender's delegated authority only after the lender receives clearance to do so from SBA.
# Question Yes No
12
Is any sole proprietor, partner, officer, director, stockholder with a 10 percent or more interest in the
Applicant an SBA employee or a Household Member of an SBA employee? (13 CFR 105.204).
"Household Member" means spouse and minor children of an employee, all blood relations of the employee
and any spouse who resides in the same place of abode with the employee (13 CFR §105.201(d)).
13
Is any employee, owner, partner, attorney, agent, owner of stock, officer, director, creditor or debtor of the
Applicant a former SBA employee who has been separated from SBA for less than one year prior to the
request for financial assistance? (13 CFR 105.203)
14
Is any sole proprietor, general partner, officer, director, or stockholder with a 10 percent or more interest in
the Applicant, or a household member of such individual, a member of Congress, or an appointed official or
employee of the legislative or judicial branch of the Federal Government? (13 CFR 105.301(c))
15
Is any sole proprietor, general partner, officer, director, or stockholder with a 10 percent or more interest in
the Applicant, or a household member of such individual, a Federal Government employee or Member of the
Military having a grade of at least GS-13 or higher (or Military equivalent)? (13 CFR 105.301(a))
16
Is any sole proprietor, general partner, officer, director, or stockholder with a 10 percent or more interest in
the Applicant, or a household member of such individual, a member or employee of a Small Business
Advisory Council or a SCORE volunteer? (13 CFR 105.302(a))
SBA Form 1919 (Revised 09/20)
5
SBA 7(a) Borrower Information Form
(Section I: Business Information)
OMB Control No.: 3245-0348
Expiration Date: 09/30/2023
By Signing Below, You Make the Following Representations, Acknowledgement, and Certification
I represent that:
• I have read the Statements Required by Law and Executive Order included in this form, and I understand them.
• I will comply, whenever applicable, with the hazard insurance, lead-based paint, civil rights and other limitations
in this form.
•
All SBA loan proceeds will be used only for business related purposes as specified in the loan
application.
• The Applicant is not knowingly engaged and will not knowingly engage in any activity that is illegal under
federal, state, or local law or that can reasonably be determined to support or facilitate any activity that is illegal
under federal, state, or local law.
• I understand, acknowledge, agree, and consent that the Lender can use and share any tax information that I have
provided and/or that the Lender has obtained from the Internal Revenue Service with SBA's authorized
representatives, including authorized representatives of the SBA Office of Inspector General, for the purpose of
compliance with SBA Loan Program Requirements and all SBA reviews.
ACKNOWLEDGEMENT
I acknowledge that:
•
SBA encourages the purchase, to the extent feasible, of American-made equipment and supplies.
ACCURACY CERTIFICATION
I certify that the information provided in this application and the information that I have provided in all supporting documents
and forms is true and accurate. I realize that the penalty for knowingly making a false statement to obtain a guaranteed loan
from SBA is that I may be fined up to $250,000 and/or be put in jail for up to 5 years under 18 USC § 1001; under 15 USC
645 by imprisonment of not more than two years and/or a fine of not more than $5,000; and, if false statements are submitted
to a Federally insured institution, I may be fined up to $1,000,000 and/or be put in jail for up to 30 years under 18 USC §
1014.
Signature of Authorized Representative of Applicant
Date:
Print Name
Title
REPRESENTATIONS
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SBA Form 1919 (Revised 09/20)
6
SBA 7(a) Borrower Information Form
(Section II: Individual Owner Information)
OMB Control No.: 3245-0348
Expiration Date: 09/30/2023
Individual Owner's Full Legal Name
Social Security / Tax ID
No.
Date of Birth
Place of Birth (City, State,
Country)
Home Address Home Phone % of Ownership
Applicant Legal Name:
Veteran/Gender/Race/Ethnicity data is collected for program reporting purposes only.
Disclosure is voluntary and has no bearing on the credit decision.
Enter Response
Veteran
1=Non-Veteran; 2=Veteran; 3=Service-Disabled Veteran; 4=Spouse of Veteran; X=Not
Gender
M=Male; F=Female; X=Not Disclosed
Race (more than 1
may be selected)
1=American Indian or Alaska Native; 2=Asian; 3=Black or African-American; 4=Native
Hawaiian or Pacific Islander; 5=White; X=Not Disclosed
Ethnicity
H=Hispanic or Latino; N=Not Hispanic or Latino; X=Not Disclosed
Question Yes No
17
Are you presently subject to an indictment, criminal information, arraignment, or other means by
which formal criminal charges are brought in any jurisdiction? (If "YES," the loan request is not
eligible for SBA assistance.)
Initial here to confirm your response to question 17 (originally initialed, or an acceptable electronic
signature, and not typed.) è
18 Have you been arrested in the last 6 months for any criminal offense?
Initial here to confirm your response to question 18 (originally initialed, or an acceptable electronic
signature, and not typed.) è
19
For any criminal offense - other than a minor vehicle violation - have you ever: 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)?
Initial here to confirm your response to question 19 (originally initialed, or an acceptable electronic
signature, and not typed.) è
If you answer "Yes" to questions 18 or 19, you must furnish details, including dates, location, fines, sentences,
level of charge (whether misdemeanor or felony), dates of parole/probation, unpaid fines or penalties, name(s)
under which charged, and any other pertinent information. If you answer "Yes" to question 19 and are currently
on parole or probation, the loan request is not eligible for SBA assistance.
20
I am a U.S. Citizen
OR
I have Lawful Permanent Resident (LPR) status.
I am not a U.S. Citizen or Lawful Permanent Resident.*
USCIS Registration
Number:
Country of Citizenship:
Initial here to confirm your response to question 20 (originally initialed, or an acceptable electronic
signature, and not typed.) è
* Businesses with ownership that includes Foreign Nationals or Foreign Entities may be eligible only if the
business is at least 51% owned and controlled by U.S. citizens and/or those who have LPR status from USCIS
whose status will be verified by the Lender in accordance with SBA Loan Program Requirements.
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SBA Form 1919 (Revised 09/20)
7
SBA 7(a) Borrower Information Form
(Section II: Individual Owner Information)
OMB Control No.: 3245-0348
Expiration Date: 09/30/2023
If any of the questions below are answered "Yes," please provide details on a separate sheet.
Question Yes No
21
Are you presently suspended, debarred, proposed for debarment, declared ineligible, or voluntarily
excluded from participation in this transaction by any Federal department or agency? (If "Yes," the
application is not eligible for SBA financial assistance)
22
If you are a 50% or more owner of the Applicant, are you more than 60 days delinquent on any
obligation to pay child support arising under an administrative order, court order, repayment
agreement between the holder and a custodial parent, or repayment agreement between the holder and
a state agency providing child support enforcement services. (If "Yes," the application is not eligible
for SBA financial assistance)
23
Do you have any ownership in other businesses which would be defined as an Affiliate of the
Applicant in the definition found on page 1? (If "Yes," attach a listing of all businesses, your title and
ownership percentage in the business.)
24 Have you, or any business you controlled, ever filed for bankruptcy protection? If yes, provide details.
25
Are you, or any business you control, presently involved in any legal action (including divorce)? If
yes, provide details.
26
Have you or any business owned or controlled by you ever obtained a direct or guaranteed loan from
SBA or any other Federal agency or been a guarantor on such a loan? (This includes, but is not
limited to USDA, FHA, EDA, and student loans.)
26 (a) If you answered "Yes" to Question 26, is any of the financing presently considered delinquent?
26
(b) If you answered "Yes" to Question 26, did any loan that was made for business purposes ever
default and cause a loss to the Government, including a compromise, resolution or settlement of a
loan's principal balance for less than the full amount due? (If you answer "Yes" to either 26(a) or
26(b) above, please provide Lender with a written explanation.)
SBA Form 1919 (Revised 09/20)
8
SBA 7(a) Borrower Information Form
(Section II: Individual Owner Information)
OMB Control No.: 3245-0348
Expiration Date: 09/30/2023
By Signing Below, You Make the Following Representations, Acknowledgement, Authorization, and Certification
REPRESENTATIONS, ACKNOWLEDGEMENT AND AUTHORIZATION
I represent that:
• I have read the Statements Required by Law and Executive Order and I understand them.
• I will comply, whenever applicable, with the hazard insurance, lead-based paint, civil rights or other limitations in this
form.
• All SBA loan proceeds will be used only for business related purposes as specified in the loan application.
• The Applicant is not knowingly engaged and will not knowingly engage in any activity that is illegal under federal,
state, or local law or that can reasonably be determined to support or facilitate any activity that is illegal under federal,
state, or local law.
• I understand, acknowledge, agree, and consent that the Lender can use and share any tax information that I have
provided and/or that the Lender has obtained from the Internal Revenue Service with SBA's authorized representatives,
including authorized representatives of the SBA Office of Inspector General, for the purpose of compliance with SBA
Loan Program Requirements and all SBA reviews.
I acknowledge that:
• SBA encourages the purchase, to the extent feasible, of American-made equipment and supplies.
I authorize the SBA to request criminal record information about me from criminal justice agencies for the purpose of
determining my eligibility for programs authorized by the Small Business Act, as amended.
ACCURACY CERTIFICATION
I certify that the information provided in this application and the information that I have provided in all supporting documents
and forms is true and accurate. I realize that the penalty for knowingly making a false statement to obtain a guaranteed loan
from SBA is that I may be fined up to $250,000 and/or be put in jail for up to 5 years under 18 USC § 1001; under 15 USC 645
by imprisonment of not more than two years and/or a fine of not more than $5,000; and, if false statements are submitted to a
Federally insured institution, I may be fined up to $1,000,000 and/or be put in jail for up to 30 years under 18 USC § 1014.
Signature
Date:
Print Name and Title
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SBA Form 1919 (Revised 09/20)
9
SBA 7(a) Borrower Information Form
(Section III: Entity Owner Information)
OMB Control No.: 3245-0348
Expiration Date: 09/30/2023
Applicant Legal Name:
Entity Owner Legal Name Tax ID
Phone
Address of Entity Owner
Primary Contact Name Email Address
Identify in what capacity you are Completing this Section? Check all that apply.
401(k) Plan ESOP Other (Explain in separate attachment):
Entity Ownership
List all proprietors, partners, officers, directors, members, Trustees, and holders of outstanding stock in the entity owner. 100%
of ownership must be disclosed. Attach a separate sheet if necessary.
Owner's Legal Name Title %
Owned
TIN
(SSN/EIN)
AddressAddress ESOP
*
401(k)
*
Co-
Op*
If any of the questions below are answered "Yes," please provide details on a separate sheet.
# Question Yes No
27
Is the Entity, or any of its owners, presently suspended, debarred, proposed for debarment, declared
ineligible, or voluntarily excluded from participation in this transaction by any Federal department or
agency? (If "Yes," the application is not eligible for SBA financial assistance).
28 Does the entity have any Affiliates? (If "Yes," attach a listing of all Affiliates.)
29 Has the entity and/or its Affiliates ever filed for bankruptcy protection?
30 Is the entity and/or its Affiliates presently involved in any pending legal action?
31
Has the Entity ever obtained a direct or guaranteed loan from SBA or any other Federal agency or been a
guarantor on such a loan? (This includes, but is not limited to USDA, FHA, EDA.)
31 (a) If you answered "Yes" to Question 31, is any of the financing presently considered delinquent?
31
(b) If you answered "Yes" to Question 31, did any loan that was for a business purpose ever default and
cause a loss to the Government, including a compromise, resolution or settlement of a loan's principal
balance for less than the full amount due?
(If you answer "Yes" to either 31(a) or 31(b) above, please provide Lender with a written explanation)
SBA Form 1919 (Revised 09/20)
10
SBA 7(a) Borrower Information Form
(Section III: Entity Owner Information)
OMB Control No.: 3245-0348
Expiration Date: 09/30/2023
By Signing Below, You Make the Following Representations, Acknowledgement, Authorization, and Certification
REPRESENTATIONS, ACKNOWLEDGEMENT AND AUTHORIZATION
I represent that:
• I have read the Statements Required by Law and Executive Order and I understand them.
• I will comply, whenever applicable, with the hazard insurance, lead-based paint, civil rights or other limitations in this
form.
• All SBA loan proceeds will be used only for business related purposes as specified in the loan application.
• The Applicant is not knowingly engaged and will not knowingly engage in any activity that is illegal under federal,
state, or local law or that can reasonably be determined to support or facilitate any activity that is illegal under federal,
state, or local law.
• I understand, acknowledge, agree, and consent that the Lender can use and share any tax information that I have
provided and/or that the Lender has obtained from the Internal Revenue Service with SBA's authorized representatives,
including authorized representatives of the SBA Office of Inspector General, for the purpose of compliance with SBA
Loan Program Requirements and all SBA reviews.
I acknowledge that:
• SBA encourages the purchase, to the extent feasible, of American-made equipment and supplies.
I authorize the SBA to request criminal record information about me from criminal justice agencies for the purpose of
determining my eligibility for programs authorized by the Small Business Act, as amended.
ACCURACY CERTIFICATION
I certify that the information provided in this application and the information that I have provided in all supporting documents
and forms is true and accurate. I realize that the penalty for knowingly making a false statement to obtain a guaranteed loan
from SBA is that I may be fined up to $250,000 and/or be put in jail for up to 5 years under 18 USC § 1001; under 15 USC 645
by imprisonment of not more than two years and/or a fine of not more than $5,000; and, if false statements are submitted to a
Federally insured institution, I may be fined up to $1,000,000 and/or be put in jail for up to 30 years under 18 USC § 1014.
Signature of Authorized Representative of Entity
Date:
Print Name and Title
SBA Form 1919 (Revised 09/20)
11
SBA 7(a) Borrower Information Form
Statements Required by Law and Executive Order
OMB Control No.: 3245-0348
Expiration Date: 09/30/2023
Please read the following notices regarding use of federal financial assistance programs and then sign
and date the certification.
This application and any assistance provided pursuant to this application is subject to the following laws, regulations,
and Executive Orders.
Privacy Act (5 U.S.C. 552a); Collection of Social Security Number (31 U.S.C.7701)
Authorities and Purpose for Collecting Information: SBA is collecting the information on this form, including social
security numbers and other personal information, to make a character and credit eligibility decision in connection with
you or your company's application for SBA assistance. SBA may also use social security numbers for the purpose of
collecting and reporting on any delinquent fees or other amounts owed SBA. Under the provisions of 31 U.S.C. 7701, the
applicant business and any guarantor of the loan are required to provide their social security numbers or other taxpayer
identification numbers in order to do business with SBA. Failure to provide this information would affect your ability to
obtain a 7(a) loan. For other individuals signing this application, the submission of the social security number is
voluntary and failure to provide your social security number may not affect any right, benefit or privilege to which you
are entitled.
In evaluating whether the applicant satisfies the criteria for a 7(a) loan, SBA considers whether the applicant and each of
its Associates possess good character. In making this determination, SBA considers the person's integrity, candor, and
criminal history if any. SBA is specifically authorized to verify your criminal history, or lack thereof, pursuant to section
7(a)(1)(B), of the Small Business Act, 15 USC Section 636(a)(1)(B). In addition, 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 Small Business Act, 15 U.S.C. 634(b)(11). In conducting the criminal background check, SBA also uses your social
security number to distinguish you from other individuals with the same or similar name or other personal identifiers.
This use is permitted under Executive Order 9397.
Routine Uses: Some of the information collected may be checked against criminal history indices of the Federal Bureau
of Investigation. When the information collected indicates a violation or potential violation of law, whether civil,
criminal, or administrative in nature, SBA may refer it 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. See SBA's Privacy Act System of Records, at 74 Fed. Reg. 14890 (2009) (as amended from time to
time) for other published routine uses for the collected information.
Right to Financial Privacy Act of 1978 (12 U.S.C. 3401) -- As required by this statute, SBA provides this notice of its
right to access your financial records held by financial institutions, including any institution participating in a loan or
loan guarantee, that are or have been doing business with you or your business. 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 loan or loan guaranty agreement. 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 access. The law also provides that SBA's access rights continue for the
term of any approved loan or 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 or
loan guarantee or to collect on a defaulted loan or loan guarantee. No other transfer of your financial records to another
Government authority will be permitted by SBA except as required or permitted by law.
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 is
generally 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 the amount of the loan, and the type of loan.
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 1919 (Revised 09/20)
12
SBA 7(a) Borrower Information Form
Statements Required by Law and Executive Order
OMB Control No.: 3245-0348
Expiration Date: 09/30/2023
Debt Collection Act of 1982 (5 U.S.C. 5514 note) and Debt Collection Improvement Act of 1996 (31 U.S.C. 3701 et
seq.) -- These laws require SBA to aggressively collect any loan or other payments that 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) or other debt
owed to SBA to credit bureaus, (2) hire a collection agency to collect your loan or other delinquent debt, (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, or (6) foreclose on collateral or take other action permitted in the loan instruments. Finally, if you default on an
SBA loan and fail to fully reimburse the Agency for any resulting loss, SBA may
refer you to the computer database of delinquent Federal debtors maintained by the Department of Housing and Urban
Development or another Federal agency. This referral may result in your being disqualified from receiving financial
assistance from other Federal agencies. In addition, unless SBA is reimbursed in full for the loss, you will not eligible for
additional SBA financial assistance.
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.) -- The Occupational Safety and Health Administration
(OSHA) can require businesses to modify facilities and procedures to protect employees. Businesses that do not comply
may be fined and required to abate the hazards in their workplaces. They may also be ordered to cease operations posing
an imminent danger of death or serious injury until employees can be protected. Signing this form is certification that the
applicant, to the best of its knowledge, is in compliance with the applicable OSHA requirements, and will remain in
compliance during the life of the loan.
Civil Rights Legislation (13 C.F.R. 112, 113, 117) -- 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.
SBA Form 1919 (Revised 09/20)
13
SBA 7(a) Borrower Information Form
Statements Required by Law and Executive Order
OMB Control No.: 3245-0348
Expiration Date: 09/30/2023
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.
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 Associates 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.
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 15 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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Completed 1 April 2022

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