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U. S. Small Business Administration DISASTER HOME / (U.S. Small Business Administration)

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OMB No. : 3245-0018
Expiration: 07/31/2021
U. S. Small Business Administration
DISASTER HOME / SOLE PROPRIETOR
LOAN APPLICATION
SBA Internal Use Only:
Date Received Location By
SBA Application Number: FEMA Registration Number:
Filing Deadline:
Declaration Number:
ARE YOU APPLYING FOR:
Primary Residence Sole Proprietor - Physical Damage
Sole Proprietor - Economic Injury
INFORMATION ABOUT THE APPLICANT(S)
Primary Applicant
First Name Middle Name
Last Name
Suffix
Social Security Number
Date of Birth
Household Size
Marital Status
Married Not Married
Are you a U.S. Citizen?
Yes No
Are you an SBA Employee?
Yes
No
CONTACT INFORMATION
Check your preferred method of contact:
E-mail Address
Cell Phone
Home Phone
Work Phone
Closest Relative Not
Living With You:
Name:
Phone Number:
Joint Applicant
First Name Middle Name
Last Name
Suffix
Social Security Number
Date of
Birth
Marital Status
Married Not Married
Are you a U.S. Citizen?
Yes No
Are you an SBA Employee?
Yes
No
Check your preferred method of
contact:
E-mail
Address
Cell Phone
Home Phone
Work Phone
DAMAGED PROPERTY ADDRESS additional damaged properties added in "additional comments" section
Address
City County
State
Zip
Type of Damage:
Real Estate
Personal Property
Automobile
MAILING ADDRESS
if different than the damaged property address.
Address
City County State Zip
DAMAGED PROPERTY INFORMATION
Do you own or rent
this property?
Own
Rent
Is this property your
Primary
Residence?
Yes No
If No, please select from the list below:
Vacation/secondary home
I own the property but a family
member/friend lives in the property
Rental/Business
Property
INCOME INFORMATION
Primary Applicant
Employed
Unemployed
Self Employed
Retired
TotalAnnualIncome(beforedeductions) $
Employer Name
Employer PhoneNumber
Note: Include all reoccurring income from all sources such as employment,
self-employment, part-time work, social security, retirement
income,
disability income, interest income, child support, alimony, etc.
Do not include one-time or non-reoccurring income.
Joint Applicant
Employed
Unemployed
Self Employed
Retired
Total Annual Income
(before deductions) $
Employer Name
Employer Phone Number
Note: Include all reoccurring income from all sources such as employment,
self-employment, part-time work, social security, retirement income,
disability income, interest income, child support, alimony, etc.
Do not include one-time or non-reoccurring income. Do not include items
covered by Primary Applicant
SBA Form 5C (05-18) Ref SOP 50 30
Page 1 of 6
DEBTS
I have no debts
Mortgage Holder or Landlord's Name (Primary Residence)
Name
Monthly Payment/Rent
$
Current Balance
$
2nd MortgageHolderName(ifapplicable)
Name
MonthlyPayment/Rent
$
Current Balance
$
Note: Please complete the section below if the amounts are NOT included in your mortgage payment:
Real Estate Taxes
$
per year
Homeowner's Insurance
$
per year
Condo/Townhome/HOA/Co-Op Fees
$
per year
Other Debt including auto payments, credit cards, installment loans, student loans, etc. Note: Only include debts that will last longer than 10 months.
Name of Creditor
Monthly Payment Current Balance
$
$
$
$
$
$
$
$
$
$
$
$
INSURANCE INFORMATION
Please check all insurance in force for the damaged property:
Homeowner's
Flood
Automobile
Renter's
No Insurance
Other:
(describe)
Policy Type
Insurance Company Name
Policy Number Phone Number Amount Received
$
$
$
OTHER DISASTER ASSISTANCE
Other than FEMA, have you received any grant award (i.e. city grants, county grants, state grants, etc.):
Yes
No
ASSETS
Pre-disaster values:
Cash, Bank Accounts and Marketable Securities (e.g. Stock & Bonds, CDs, etc.) (Not including retirement accounts) . . . . . . . . . . . . . . . . . . . ... . . .. . $
Retirement Accounts (e.g. IRAs, Keogh, TSP or other similar accounts). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ... . .$
Personal Property (furniture, appliances, vehicles, RVs, etc.). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
Primary Residence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
All Other Real Estate (describe)
$
DISCLOSURES
The responses below apply to the Applicant and Joint Applicant, if any. Please explain any "Yes" responses on the last page.
1.
Are you delinquent on any Federal taxes, Federal loans, Federal grants, or 60 days past due on any child support obligation? . . . . . .. .
Yes
No
2.
Are you currently a defendant in any lawsuits or have pending judgements against you?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .
Yes
No
3.
Are you currently suspended or debarred from contracting with Federal government or receiving Federal grants or loans?. . . . . . . . . . . . . . . . . . . .
Yes
No
4.
Do you have federal loans, federally guaranteed loans, or previous SBA loans? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Yes
No
5.
Are you engaged in the production or distribution of any product that has been determined to be obscene by a court of competent
jurisdiction? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Yes
No
6.
In the past year, have you been convicted of a felony committed in connection with a riot or civil disorder?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .
Yes
No
7.
Are you presently, a) subject to an indictment, criminal information, arraignment, or other means by which formal criminal charges are brought in any
jurisdiction; b) have you been arrested in the past six months for any criminal offense; c) for any criminal offense -other than a minor vehicle violation
-- have you ever: 1) been convicted, 2) plead guilty, 3) plead nolo contendere, 4) been placed on pretrial diversion, or 5) been placed on any form of
parole or probation (including probation before judgment)?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SBA Form 5C (05-18) Ref SOP 50 30
Page 2 of 6
Yes
No
REPRESENTATIVE INFORMATION
If you have paid a representative (packager, attorney, accountant, etc.) to assist you in completing the application, please complete the section below:
Name and Address of Representative: Fee charged or agreed upon
$
CONSENT
I authorize my insurance company, bank, financial institution, or other creditors to release to SBA all records and financial information necessary to process this application.
SBA has my permission, as required by the Privacy Act, to release any information collected in connection with this application to Federal, state, local, tribal or nonprofit organizations
(e.g.RedCross,SalvationArmy, MennoniteDisasterServices, SBAResource Partners)forthepurposeof assistingme withmySBA application, evaluatingmyeligibilityforadditional
disaster assistance, or notifying me of the availability of such assistance.
If my loan is approved, I may be eligible for additional funds to safeguard my property from damages similar to those caused by this disaster. Although it is not necessary for me to
provide with my application, a description and cost estimate will be required prior to SBA approval of the mitigation measure.
I have received and read a copy of the "STATEMENTS REQUIRED BY LAWS AND EXECUTIVE ORDERS" which was attached to this application.
CERTIFICATION ASTOTRUTHFUL INFORMATION: Bysigning this application, you certify that all information in your application and submitted with your application istrue 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 SBA 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 or misrepresentation to SBA may result in criminal, civil or administrative sanctions including, but not
limited to: 1)fines and imprisonment, orboth, under 15U.S.C. 645, 18U.S.C. 1001, 18U.S.C. 1014, 18U.S.C. 1040, 18U.S.C. 3571, andany 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-procurement transactions. Statutory fines may increase if amended by the Federal Civil Penalties Inflation Adjustment Act
Improvements Act of 2015.
Signature of Applicant Date Signature of Joint Applicant Date
ADDITIONAL COMMENTS
SBA Form 5C (05-18) Ref SOP 50 30
Page 3 of 6
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U.S. Small Business Administration
DISASTER HOME LOAN APPLICATION
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 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 Email to discuss your loan request.
FILING REQUIREMENTS
REQUIRED FOR ALL LOAN APPLICATIONS:
■
Complete and sign this application form (SBA Form 5C)
■
Complete and sign the Tax Information Authorization (IRS Form 4506T) enclosed with
this application. This income information, obtained from the IRS, will help us determine
your repayment ability. U.S. Territories that have their own taxing authority outside of the
IRS may require additional form(s) in order to obtain copies of their transcripts. The
exact form(s) required will be determined at the onset of the declared disaster. All other
filing requirements remain the same.
WHILE NOT NECESSARY TO ACCEPT YOUR APPLICATION, YOU MAY BE REQUIRED TO SUPPLY
THE FOLLOWING INFORMATION TO PROCESS THE APPLICATION. IF REQUESTED, PLEASE
PROVIDE WITHIN 7 DAYS OF THE INFORMATION REQUEST:
■
If any applicant has changed employment within the past two years, provide a copy of a
current (within 1 month of the application date) pay stub for all applicants
■
If we need additional income information, you may be asked to provide copies of your
Federal income tax returns, including all schedules
IF SBA APPROVES YOUR LOAN, WE MAY REQUIRE THE FOLLOWING ITEMS BEFORE LOAN
CLOSING. WE WILL ADVISE YOU, IN WRITING, OF THE DOCUMENTS WE NEED.
■
If you own your residence, a COMPLETE legible copy of the deed, including the legal
description of the property
■
If the damaged property is your primary residence, proof of residency at the damaged
address
■
If you had damage to a manufactured home, a copy of the title. If you own the lot where
the home is located, a COMPLETE legible copy of the deed, including the legal description
of the property
■
If you have damage to an automobile or other vehicle, proof of ownership (a copy of the
registration, title, bill of sale, etc.)
SBA Form 5C (05-18) Ref SOP 50 30
Page 4 of 6
NOTE: PLEASE READ, DETACH AND KEEP FOR YOUR RECORDS
STATEMENTS REQUIRED BY LAWS AND EXECUTIVE ORDERS
Tocomply with legislation passed bytheCongress andExecutive Orders issued bythePresident, Federal executive agencies,
including theSmall Business Administration (SBA), must notify you ofcertain information. You can find theregulations andpolicies
implementing these laws and Executive Orders in Title 13, Code of Federal Regulations (CFR), Chapter 1, or our Standard Operating
Procedures (SOPs). Inorder toprovide therequired notices, thefollowing isa brief summary ofthevarious lawsandExecutive 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 orpartners), loan amounts at maturity, the
collateral pledged, and the general purpose of loans. Wedo not routinely make available to third parties your proprietary data
without first notifying you, asrequired byExecutive Order #12600, orinformation thatwould cause competitive harm orconstitute
a clearly unwarranted invasion of personal privacy.
Freedom ofInformationAct (FOIA) requests must describe the specific records you want. For information abouttheFOIA, contact
the Chief, FOI/PA Office, 4093rd Street, SW, Suite 5900,Washington, DC 20416, or by e-mail at f
oia@sba.gov.
PRIVACY ACT (5 U.S.C. § 552a)
Anyone can request to see orgetcopies of anypersonal information that wehave in your file. Any personal information inyour file
that is retrieved byindividual 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 collection to
state, local or private disaster relief services.
The Privacy Act authorizes SBA tomake certain "routine uses" ofinformation protected bythat 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 orotherwise involved ininvestigation, prosecution, enforcement orprevention of such violations. Another routine
use of personal information isto assist in obtaining credit bureau reports, on the Disaster Loan Applicants and guarantors for
purposes oforiginating, servicing, andliquidating Disaster loans. See, 69F.R. 58598,58617(and asamended from time totime) for
additional background and other routine uses.
Under theprovisions of thePrivacy Act, you are notrequired toprovide social security numbers. (But see theinformation under
Debt Collection Act below) Weuse social security numbers todistinguish between people with a similar orthesame name for
credit decisions andfor debt collection purposes. Failure toprovide this number may not affect any right, benefit orprivilege to
which you are entitled bylaw, 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 3rd 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.
SBA Form 5C (05-18) Ref SOP 50 30
Page 5 of 6
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. Ifyou 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.
*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, asrequired bytheRight to Financial Privacy Act of1978(Act), ofourright toaccess financial records
held byfinancial institutions thatwere orare doing business with you oryour business. This includes financial institutions
participating in loans or loan guarantees.
The law provides thatwemay access your financial records when considering oradministering Government loan orloan
guaranty assistance toyou. Wemust give a financial institution a certificate of ourcompliance with theAct when wefirst
request access toyour financial records. Noothercertification isrequired 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
approvedloanorloanguarantyasnecessarytoprocess,service,liquidate,orforeclosealoanorloanguaranty.Wewill
notpermitanytransferof your financial records toanother Government authorityexceptasrequiredorpermittedbylaw.
CONSUMER CREDIT PROTECTION ACT
(15
U.S.C.
1601
et seq.)
This legislation gives an applicant who isrefused credit because of adverse information about the applicant's credit,
reputation, character ormode ofliving anopportunity torefute orchallenge theaccuracy ofsuch reports. Therefore, ifwe
decline your loan in whole or in part because of adverse information in a credit report, you will be given the name and
address of the reporting agency so you can seek to have that agency correct its report, if inaccurate. If we decline your
loan inwhole orinpart because of adverse information received from a source other thana credit reporting agency, you
will be given information but not the source of the report.
Within3daysaftertheconsummation of the transaction, anyrecipientof anSBA loanwhichissecuredinwholeorinpart
byalienontherecipient'sresidenceorhouseholdcontentsmayrescindsuchaloaninaccordancewith"RegulationZ"of
the Federal Reserve Board.
PLEASE NOTE: The estimated burden for completing this form is 1.25 hours. Your responses to the requested information
are required in order to obtain a benefit under our Disaster Home Loan Program. However, you are not required to
respond toany collection ofinformation unless itdisplays a currently valid OMB approval number. Ifyou have questions
or comments concerning any aspects of this information collection, please contact the U.S. Small Business Administration
Information Branch, 4093rd Street, SW, Washington, DC20416 andDesk Officer for SBA,Office ofManagement and
Budget, Office of Information and Regulatory Affairs, 725 17th Street, NW, Washington, DC 20503. (3245-0018) PLEASE DO
NOT SEND FORMS TO OMB.
Page 6 of 6
SBA Form 5C (05-18) Ref SOP 50 30
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