Fillable U.S. SMALL BUSINESS ADMINISTRATION COVID-19 ECONOMIC INJURY DISASTER (U.S. Small Business Administration)

Fill Online, Printable, Fillable, Blank U.S. SMALL BUSINESS ADMINISTRATION COVID-19 ECONOMIC INJURY DISASTER (U.S. Small Business Administration) Form

Use Fill to complete blank online U.S. SMALL BUSINESS ADMINISTRATION (DC) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

U.S. SMALL BUSINESS ADMINISTRATION COVID-19 ECONOMIC INJURY DISASTER (U.S. Small Business Administration)

On average this form takes 30 minutes to complete

The U.S. SMALL BUSINESS ADMINISTRATION COVID-19 ECONOMIC INJURY DISASTER (U.S. Small Business Administration) form is 17 pages long and contains:

  • 1 signature
  • 17 check-boxes
  • 110 other fields

Country of origin: US
File type: PDF

U.S.A. forms for U.S. Small Business Administration

BROWSE U.S. SMALL BUSINESS ADMINISTRATION (DC) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
OMB Control Number 3245-0406
Expiration Date: 9/30/2020
U.S. SMALL BUSINESS ADMINISTRATION
COVID-19 ECONOMIC INJURY DISASTER LOAN APPLICATION
SBA is collecting the requested information in order to make a loan under SBA’s Economic
Injury Disaster Loan Program to the qualified entities listed in Question 3-Organization Type
below that are impacted by the Coronavirus (COVID-19). The information will be used in
determining whether the applicant is eligible for an economic injury loan. If you do not submit
all the information requested, your loan cannot be fully processed.
If you have questions about this application or problems providing the required information,
please contact our Customer Service Center at 1-800-659-2955 or
(TTY:
1-800-877-8339) or
DisasterCustomerService@sba.gov
.
If more space is needed for any section of this application, please attach additional sheets.
SBA will contact you by phone or e-mail to discuss your loan request.
FILING REQUIREMENTS
You must complete and submit the following:
☐ This application (SBA Form 3501), completed and signed
☐ Economic Injury Disaster Loan Supporting Information (SBA Form 3502)
☐ Self-Certification for Verification of Eligible Entity for Emergency Economic Injury
Disaster Loan Advance (SBA Form 3503)
FOR INTERNAL SBA USE ONLY
Economic Injury Declaration Number:
SBA Application Number:
Date Received:
By:
Filing Deadline Date:
SBA Form 3501 (04/20)
U.S. SMALL BUSINESS ADMINISTRATION
OMB Control Number 3245-0406
Expiration Date: 9/30/2020
COVID-19 ECONOMIC INJURY DISASTER LOAN APPLICATION
PLEASE NOTE: The estimated time for completin g this portion of the application is 30 minutes. You
are not required to respond
to thi
s or any collection of information unless it display
s a currently
valid
OMB approval number.
If you have any
question
s or comments concerning any
aspects of this
information collection, please contact the U.S. Small Business Administration Information
Branch, 409
3rd St., SW,
Washi
ngton, DC 20416 and Desk Officer for SBA, Office of Management an
d Budget,
Office of Information
and Regulatory Affai
rs, New Executive Office Building , Washi
ngton
, D
C
20503.
BUSINESS INFORMATION
1.
Legal Name of Business:
2. Trade Name: (Insert DBA name if different than legal name)
3. Organization Type:
Cooperative
Employee Stock Ownership Plan(ESOP)
Sole Proprietor
Independent Contractor
Tribal Business
Partnership
SBA Form 3501 (04/20)
OMB Control Number 3245-0406
Expiration Date: 9/30/2020
Corporation
Limited Partnership
Nonprofit Organization
Limited Liability Entity (LLC, LLP)
Trust
Other:
4.
Federal Employer Identification Number
(EIN), if applicable, or Social Security
Number:
5.
Business Phone Number:
6. Mailing Address:
Street:
City:
State: ZIP code:
7. Business Property Address(es):
Address 1
Street:
City:
State:
ZIP code:
Address 2
Street:
City:
State:
Zip code:
Address 3
Street:
City:
State: ZipCode:
SBA Form 3501 (04/20)
OMB Control Number 3245-0406
Expiration Date: 9/30/2020
8. Provide name of individual to contact for information necessary to
process the
application:
Phone Number:
Alternative contact
information:
☐ Phone
☐ Email
☐ Fax Number
☐ Other contact information
9. Business Activity (e.g., restaurant, r
etail):
10. Number of Employees
Pre-disaster:
11. Date Business Established (MM/DD/YYYY)
:
12. Current Management Since
:
13. Amount in U.S. Dollars of Estimated Loss:
14. Owner Information.
Complete for Each:
a. Proprietor, or
b. Limited
partner who owns 20% or more
interest
and
each
general partner,
or
c. Stockholder or entity owning 20% or more voting stock.
If you need more space, include documentation on additional
information pages.
Owner #1:
Legal Name:
Title/Office:
Percentage Owned:
Email Address:
Social Security Number*:
SBA Form 3501 (04/20)
No
OMB Control Number 3245-0406
Expiration Date: 9/30/2020
Date of Birth:
Place of Birth:
City*:
Telephone Number:
State*:
US Citizen? ☐ Yes ☐ No
Mailing Address
Street:
City:
Owner #2:
State: ZIP code:
Legal Name:
Title/Office:
Percentage Owned:
Email Address:
Social
Security Number*:
Date
of
Birth:
Place of Birth*:
City:
Telephone Number:
US
Citizen?
Yes
State:
Mailing Address
Street:
City:
Business Entity Owner:
EIN:
State:
ZIP code:
SBA Form 3501 (04/20)
OMB Control Number 3245-0406
Expiration Date: 9/30/2020
Type of Business:
% Ownership:
Mailing Address
Street:
City:
State:
ZIP code:
Email Address:
Phone:
15. Applicant business and
each owner listed on this application,
please respond to the
following questions,
providing dates and details
on any question answered
YES
(Attach additional sheets as needed).
a. In the past year, has the business or a listed owner been convicted of a felony
committed during and in connection with a riot or civil disorder or other declared
disaster, or ever been engaged in the production or distribution of any product or
service that has been determined to be obscene by a court of competent
jurisdiction?
☐ Yes
☐ No
b. Is the applicant or any listed owner currently suspended or debarred from
contracting with the Federal government or receiving Federal grants or loans?
☐ Yes
☐ No
16. Regarding you or any owner listed on this application:
a. Are you presently subject to an indictment, criminal information, arraignment, or
other means by which formal criminal charges are brought in any jurisdiction?
SBA Form 3501 (04/20)
OMB Control Number 3245-0406
Expiration Date: 9/30/2020
b. Within the last 5 years, for any felony, have you:
• Been convicted; or
• Plead guilty; or
• Plead nolo contendere; or
• Been placed on pretrial diversion; or
• Been placed on any form of parole or probation (including probation before
judgment)?
☐ Yes
☐ No
If yes, enter name of individual:
17.
If anyone assisted you in completing this application, whether you pay a fee for this
service or not, please provide the following information
:
Individual Name:
Address of Representative
Street:
City: State: ZIP code:
Name of Company:
Phone Number:
Address of Company
Street:
State: ZIP code:
City:
Fee in U.S. Dollars Charged or Agreed Upon:
☐
I give SBA permission to discuss any portion of this application with the
representative listed above.
☐
I DO NOT
give SBA permission to discuss any portion of this application with
the representative listed above.
SBA Form 3501 (04/20)
OMB Control Number 3245-0406
Expiration Date: 9/30/2020
18. ACH Information
Bank Name:
Routing Number:
Account Number:
SBA Form 3501 (04/20)
OMB Control Number 3245-0406
Expiration Date: 9/30/2020
U.S. SMALL BUSINESS ADMINISTRATION
ECONOMIC INJURY DISASTER LOAN
AGREEMENTS AND CERTIFICATIONS
On behalf of the undersigned individually and for the applicant business:
I/W e authorize my/our insurance company, bank, financial institution, or other creditors
to release to SBA all records and i nformation necessary to process this application and for
the SBA to obtain credit information about the individuals completing this application.
If
my/our
loan is approved,
additional
information
may
be
required
prior
to
loan closing.
I/We
will be
advised
in writing
what
information
will be
required
to
obtain
my/our
loan funds. I/We
hereby
authorize
the SB
A to
verify
my/our
past
and
present
employment
information
and
salary
history
as
needed
to
process
and
service
a disaster
loan.
I/We
authorize
SBA,
as
required by
the
Privacy
Act,
to
release
any
information
collected i
n
connection
with
this
application
to
Federal,
state,
local,
tribal
or
nonprofit
organizations
(e.g.
Red
Cross Salvation
Army,
Mennonite
Disaster
Services,
SBA
Resource
Partners)
for
the
purpose
of
assisting
me
with
my/our
SBA
application,
evaluating
eligibility
for
additional
assistance,
or
notifying
me
of the availability of such
assistance.
I/We
will
not
exclude
from
participating
in
or
deny
the
benefits
of,
or
otherwise
subject
to
discrimination
under
any
program
or
activity
for
which
I/we
receive
Federal
financial
assistance
from
SBA,
any
person
on
grounds
of age,
color,
handicap,
marital
status,
national
origin,
race,
religion,
or
sex.
I/We
will
report
to
the
SBA
Office
of
the
Inspector
General,
Washington,
DC
20416,
any
Federal
employee w
ho
offers,
in
return
for
compensation
of
any k
ind,
to
help
get
this
loan
approved.
I/We have not
paid
anyone connected
with
the Federal government
for
help
in
getting this
loan.
C ERTIFICATION
AS
TO TRUTHFUL
INFORMATION:
By
signing
this
application,
you
certify
that
all
information
in
your
application
and
submitted
with
your
application
is
true
and
correct
to
the
best of your knowledge,
and that you will submit
truthful information in the
future.
WARNING:
Whoever
wrongfully misapplies the proceeds of
an S
BA
disaster
loan
shall be
civilly liable to
the Administrator
in
an
amount
equal to
one-and-one half
times the
original
principal amount of the loan under 15 U.S.C. 636(b). In addition, any false statement
SBA Form 3501 (04/20)
OMB Control Number 3245-0406
Expiration Date: 9/30/2020
or misrepresentation
to
SBA
may
result
in criminal,
civil or administrative
sanctions
including,
but not limited
to:
1) fines and imprisonment,
or
both,
under
15
U.S.C.
645, 18
U.S.C.
1001,
18
U.S.C.
1014,
18
U.S.C.
1040,
18
U.S.C.
3571,
and any
other
applicable
laws;
2) treble
damages
and
civil
penalties
under
the False Claims Act, 31
U.S.C. 3729; 3) double damages and civil penalties
under the Program Fraud Civil
Remedies
Act, 31 U.S.C. 3802; and 4) suspension and/or
debarment
from all Federal
procurement
and non-p
rocurement
transactions.
Statutory
fines
may
increase
if
amended
by the Federal
Civil Penalties
Inflation
Adjustment Act Improvements Act of
2015.
Date:
Signature:
Signatory Name:
Title:
SBA Form 3501 (04/20)
U.S. SMALL BUSINESS ADMINISTRATION
OMB Control Number 3245-0406
Expiration Date: 9/30/2020
COVID-19 ECONOMIC INJURY DISASTER LOAN APPLICATION
Enter additional information here. Please refer to section and title.
SBA Form 3501 (04/20)
OMB Control Number 3245-0406
Expiration Date: 9/30/2020
U.S. SMALL BUSINESS ADMINISTRATION
STATEMENTS REQUIRED BY LAWS AND EXECUTIVE ORDERS
NOTE: PLEASE READ AND KEEP FOR YOUR RECORDS
To comply with legislation passed by the Congress and Executive Orders issued by the
President, Federal executive agencies, including the Small Business Administration (SBA),
must notify you of certain information. You can find the regulations and policies
implementing these laws and Executive Orders in Title 13, Code of Federal Regulations
(CFR), Chapter 1, or our Standard Operating Procedures (SOPs). In order to provide the
required notices, the following is a brief summary of the various laws and Executive Orders
that affect SBA's Disaster Loan Programs. A glossary of terms can be found at
Disasterloan.sba.gov.
FREEDOM OF INFORMATION ACT (5 U.S.C. § 552)
This law provides, with some exceptions, that we must make records or portions of records
contained in our files available to persons requesting them. This generally includes
aggregate statistical information on our disaster loan programs and other information
such as names of borrowers (and their officers, directors, stockholders or partners), loan
amounts at maturity, the collateral pledged, and the general purpose of loans. We do not
routinely make available to third parties your proprietary data without first notifying you,
required by Executive Order 12600, or information that would cause competitive harm or
constitute a clearly unwarranted invasion of personal privacy.
Freedom of Information Act (FOIA) requests must describe the specific records you want.
For information about the FOIA, contact the Chief, FOI/PA Office, 409 3
rd
Street, SW, Suite
5900, Washington, DC 20416, or by e-mail at foia@sba.gov.
PRIVACY ACT (5 U.S.C. § 552a)
Anyone can request to see or get copies of any personal information that we have in your
file. Any personal information in your file that is retrieved by individual identifiers, such as
name or social security number is protected by the Privacy Act, which means requests for
information about you may be denied unless we have your written permission to release
the information to the requestor or unless the information is subject to disclosure under
the Freedom of Information Act. The Agreements and Certifications section of this form
contains written permission for us to disclose the information resulting from this
SBA Form 3501 (04/20)
OMB Control Number 3245-0406
Expiration Date: 9/30/2020
collection to state, local or private disaster relief services.
The Privacy Act authorizes SBA to make certain "routine uses" of information protected by
that Act. One such routine use for SBA's loan system of records is that when this
information 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. Another routine
use of personal information is to assist in obtaining credit bureau reports, on the Disaster
Loan Applicants and guarantors for purposes of originating, servicing, and liquidating
Disaster loans. See, 69 F.R. 58598, 58617 (and as amended from time to time) for additional
background and other routine uses.
Under the provisions of the Privacy Act, you are not required to provide social security
numbers. (But see the information under Debt Collection Act below) We use social security
numbers to distinguish between people with a similar or the same name for credit
decisions and for debt collection purposes. Failure to provide this number may not affect
any right, benefit or privilege to which you are entitled by law, but having the number
makes it easier for us to more accurately identify to whom adverse credit information
applies and to keep accurate loan records.
Note: Any person concerned with the collection, use and disclosure of information, under
the Privacy Act may contact the Chief, FOI/ PA Office, 409 3
rd
Street, SW, Suite 5900,
Washington, DC 20416 or by e-mail at foia@sba.gov for information about the Agency's
procedures relating to the Privacy Act and the Freedom of Information Act.
DEBT COLLECTION ACT OF 1982; DEFICIT REDUCTION ACT OF 1984; DEBT
COLLECTION IMPROVEMENT ACT OF 1996 & OTHER TITLES (31 U.S.C. 3701 ET SEQ.)
These laws require us to aggressively collect any delinquent loan payments and to require
you to give your taxpayer identification number to us when you apply for a loan. If you
receive a loan and do not make payments when they become due, we may take one or
more of the following actions (this list may not be exhaustive):
•
Report the delinquency to credit reporting bureaus.
•
Offset your income tax refunds or other amounts due to you from the Federal
Government.
•
Refer the account to a private collection agency or other agency operating a debt
collection center.
•
Suspend or debar you from doing business with the Federal Government.
SBA Form 3501 (04/20)
OMB Control Number 3245-0406
Expiration Date: 9/30/2020
•
Refer your loan to the Department of Justice.
•
Foreclose on collateral or take other actions permitted in the loan instruments.
•
Garnish wages.
•
Sell the debt.
•
Litigate or foreclose.
RIGHT TO FINANCIAL PRIVACY ACT OF 1978 (12 U.S.C. § 3401 ET SEQ.)
This notifies you, as required by the Right to Financial Privacy Act of 1978 (Act), of our right
to access financial records held by financial institutions that were or are doing business
with you or your business. This includes financial institutions participating in loans or loan
guarantees.
The law provides that we may access your financial records when considering or
administering Government loan or loan guaranty assistance to you. We must give a
financial institution a certificate of our compliance with the Act when we first request
access to your financial records. No other certification is required for later access. Our
access rights continue for the term of any approved loan or loan guaranty. We do not have
to give you any additional notice of our access rights during the term of the loan or loan
guaranty.
We may transfer to another Government authority any financial records included in a loan
application or about an approved loan or loan guaranty as necessary to process, service,
liquidate, or foreclose a loan or loan guaranty. We will not permit any transfer of your
financial records to another Government authority except as required or permitted by law.
POLICY CONCERNING REPRESENTATIVES AND THEIR FEEDS
When you apply for an SBA loan, you may use an attorney, accountant, engineer, appraiser
or other representative to help prepare and present the application to us. You are not
required to have representation. If an application is approved, you may need an attorney
to help prepare closing documents.
There are no “authorized representatives” of SBA, other than our regular salaried
employees. Payment of a fee or gratuity to our employees is illegal and will subject those
involved to prosecution.
SBA Form 3501 (04/20)
OMB Control Number 3245-0406
Expiration Date: 9/30/2020
SBA Regulations prohibit representatives from proposing or charging any fee for services
performed in connection with your loan unless we consider the services necessary and the
amount reasonable. The Regulations also prohibit charging you any commitment, bonus,
broker, commission, referral or similar fee. We will not approve the payment of any bonus,
brokerage fee or commission. Also, w e will not approve placement or finder's fees for using
or trying to use influence in the SBA loan application process.
Fees to representatives must b e reasonable for services provided in connection with the
application or the closing and based upon the time and effort required, the qualifications
of the representative, and the nature and extent of work performed.
Representatives must execute a compensation agreement.
In the appropriate section of the application, you must state the names of everyone
employed by you or on your behalf. You must also notify the SBA disaster office in writing
of the names and fees of any representative you employ after you file your application.
If you have any questions concerning payment of fees or reasonableness of fees, contact
the Field Office where you f iled or will file your application.
OCCUPATIONAL SAFETY AND
HEALTH
ACT
(29 U.S.C. 3651 ET
SEQ.)
This legislation authorizes the Occupational Safety a
nd Health Administration (OSHA) i
n the
Department of Labor to require businesses to modify facilities
and procedures to
protect
employees when appropriate. If your business does not do so, yo
u may be
penalized, forced
to
close or prevented from starting operations
in
a new facility
. Because
of this, we may require
information from you to
determine whether you
r business complies with OSHA regulations and
may continue operating after the
loan is approved or disbursed. You
must
certify to
us that OSHA
requirements applying to you
r business have been determined and
that you a
re,
to the best
of
your knowledge, in compliance
SBA Form 3501 (04/20)
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

U.S. SMALL BUSINESS ADMINISTRATION COVID-19 ECONOMIC INJURY DISASTER (U.S. Small Business Administration)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 22 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document