1. Purpose. Veteran/gender/race/ethnicity data is collected for program reporting purposes only.
2. Description. This form requests information about each of the Borrower’s Principals. Add additional sheets if necessary.
3. Definition of Principal. The term “Principal” means:
• For a self-employed individual, independent contractor, or a sole proprietor, the self-employed individual, independent contractor, or sole proprietor.
• For a partnership, all general partners and all limited partners owning 20% or more of the equity of the Borrower, or any partner that is involved in the management of the Borrower’s business.
• For a corporation, all owners of 20% or more of the Borrower, and each officer and director.
• For a limited liability company, all members owning 20% or more of the Borrower, and each officer and director.
• Any individual hired by the Borrower to manage the day-to-day operations of the Borrower (“key employee”).
• Any trustor (if the Borrower is owned by a trust).
• For a nonprofit organization, the officers and directors of the Borrower.
4. Principal Name. Insert the full name of the Principal.
5. Position. Identify the Principal’s position; for example, self-employed individual; independent contractor; sole proprietor; general partner; owner; officer; director; member; or key employee.
1=Non-Veteran; 2=Veteran; 3=Service-Disabled Veteran; 4=Spouse of Veteran; X=Not Disclosed
M=Male; F=Female; X=Not Disclosed
1=American Indian or Alaska Native; 2=Asian; 3=Black or African-American; 4=Native Hawaiian or Pacific Islander; 5=White; X=Not Disclosed
H=Hispanic or Latino; N=Not Hispanic or Latino; X=Not Disclosed
(1) Bank account statements or third-party payroll reports for cash compensation
(2) Payroll tax filings to IRS
(3) State quarterly Wage and Unemployment Insurance Tax Filings
(4) Payment receipts, cancelled checks, or account statements for Employer Contributions to Health Insurance
(5) Payment receipts, cancelled checks, or account statements for Employer Contributions to Retirement Plans
Payroll Tax Filings to IRS and State Quarterly Wage & Unemployment Tax Filings for Chosen Reference Period:
(1) February 15, 2019 - June 30, 2019
(2) January 1, 2020 - February 29, 2020; OR
(3) Selected time period per SBA Form 3508 Revised June 16, 2020 (06/20) for Seasonal Employers
Please note that certain documentation requires the verification of the existence of obligations/ services as of February 15, 2020 and one month after the end of the Covered Period.
(1) Business Mortgage Interest Payments
(2) Business Rent or Lease Payments
(3) Business Utility Payments
By Signing Below, You Make the Following Representations and Certifications on Behalf of the Borrower:
The authorized representative of the Borrower certifies to all of the below by initialing next to each one.
The dollar amount for which forgiveness is requested:
I understand that if the funds were knowingly used for unauthorized purposes, the federal government may pursue recovery of loan amounts and/or civil or criminal fraud charges.
The Borrower has accurately verified the payments for the eligible payroll and nonpayroll costs for which the Borrower is requesting forgiveness.
I have submitted to the Lender the required documentation verifying payroll costs, the existence of obligations and service (as applicable) prior to February 15, 2020, and eligible business mortgage interest payments, business rent or lease payments, and business utility payments.
The information provided in this application and the information provided in all supporting documents and forms is true and correct in all material respects. I understand that knowingly making a false statement to obtain forgiveness of an SBA-guaranteed loan is punishable under the law, including 18 USC 1001 and 3571 by imprisonment of not more than five years and/or a fine of up to $250,000; under 15 USC 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, under 18 USC 1014 by imprisonment of not more than thirty years and/or a fine of not more than $1,000,000.
The tax documents I have submitted to the Lender are consistent with those the Borrower has submitted/will submit to the IRS and/or state tax or workforce agency. I also understand, acknowledge, and agree that the Lender can share the tax information with SBA’s authorized representatives, including authorized representatives of the SBA Office of Inspector General, for the purpose of ensuring compliance with PPP requirements and all SBA reviews.
I understand, acknowledge, and agree that SBA may request additional information for the purposes of evaluating the Borrower’s eligibility for the PPP loan and for loan forgiveness, and that the Borrower’s failure to provide information requested by SBA may result in a determination that the Borrower was ineligible for the PPP loan or a denial of the Borrower’s loan forgiveness application.
If the Borrower has checked the box for FTE Reduction Safe Harbor 1 on PPP Schedule A, the Borrower was unable to operate between February 15, 2020 and the end of the Covered Period at the same level of business activity as before February 15, 2020 due to compliance with requirements established or guidance issued between March 1, 2020 and December 31, 2020, by the Secretary of Health and Human Services, the Director of the Centers for Disease Control and Prevention, or the Occupational Safety and Health Administration, related to the maintenance of standards of sanitation, social distancing, or any other work or customer safety requirement related to COVID-19.
The Borrower’s eligibility for loan forgiveness will be evaluated in accordance with the PPP regulations and guidance issued by SBA through the date of this application. SBA may direct a lender to disapprove the Borrower’s loan forgiveness application if SBA determines that the Borrower was ineligible for the PPP loan.
Your SBA PPP Loan Forgiveness Application to the Bank is almost complete.
After submitting this document, you will receive an on-screen confirmation of your submission and a pdf of your application. Please download this file to save for your personal records. You will additionally receive an email confirmation of your submission.
Click "Submit" to electronically send your Application to the Bank.