Free SBA FORM 4 Application For Business Loan - Federal

Reset Form
OMB Approval No. 3245-0016 Expiration Date: 8/31/2009

U. S. Small Business Administration

APPLICATION FOR BUSINESS LOAN
Individual Full Address

Name of Applicant Business

Tax I.D. No. or SSN

Full Street Address of Business

Tel. No. (inc. Area Code)

City

County

State

Zip

Number of Employees (including subsidiaries and affiliates) At Time of Application If Loan is Approved _______ _______

Type of Business

Date Business Established

Bank of Business Account and Address Subsidiaries or Affiliates _______ (Separate for above)

Use of Proceeds: (Enter Gross Dollar Amounts Rounded to the Nearest Hundreds) Land Acquisition New Construction/ Expansion Repair Acquisition and/or Repair of Machinery and Equipment Inventory Purchase Working Capital (including Accounts Payable) Acquisition of Existing Business

Loan Requested

Loan Request

Pay off SBA Loan Pay off Bank Loan (Non SBA Associated)* Other Debt Payment (Non SBA Associated) All Other Total Loan Requested Term of Loan - (Requested Mat.) Yrs.

CURRENT AND PREVIOUS SBA AND OTHER GOVERNMENT DEBT: Complete the chart for the following: 1) SBA loan applications pending for the applicant or any of its affiliates; 2) Federal debt, including SBA, received by the applicant including loans that have been paid in full or charged off; 3) Federal debt (including student loans and disaster loans) borrowed by any principal of the applicant; 4) Federal debt borrowed by any other business currently or previously owned by any principal of the applicant. If there has been a loss to the government as a result of a charge off, compromise, or discharge due to bankruptcy for any of the listed debt, it must be identified below. LOSS is the outstanding principal balance of the loan that the government agency had to write off after all collection activities (including compromises) were finalized. Name of Agency Agency Loan # Borrower's Name Original Amount of Loan Date of Application Loan Status Outstanding Balance $ Amount of Loss to the Gov't.

$ # $ #

$ $

$ $

ASSISTANCE List below the name(s), occupation, and address of anyone (including the lender) who assisted in the preparation of this form and who received (or
will receive) compensation from the applicant for this assistance. For any person listed, an SBA Form 159 must be completed by the applicant and listed person and submitted as part of the application. The lender must complete the "Lender's Certification" on any SBA Form 159 prior to the loan being approved.

Name and Occupation

Address

Total Fees Paid

Fees Due

Name and Occupation

Address

Total Fees Paid

Fees Due

Note: The estimated burden completing this form is 12.0 hours per response. You will not be required to respond to collection of information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to the U.S. Small Business Administration, Chief, AIB, 409 3rd St., S.W., Washington, DC. 20416 and Desk Office for Small Business Administration, Office of Management and Budget, New Executive Building, room 10202 Washington, D.C. 20503. OMB Approval (3245-0016). PLEASE DO NOT SEND FORMS TO OMB. SUBMIT COMPLETED APPLICATION TO LENDER OF CHOICE.

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ALL EXHIBITS MUST BE SIGNED AND DATED BY PERSON SIGNING THIS FORM
BUSINESS INDEBTEDNESS: Furnish the following information on all outstanding installment debts, contracts, notes, and mortgages payable. Indicate by an asterisk (*) items to be paid by loan proceeds and reasons for paying them. (Present balance should agree with the latest balance sheet submitted). Current or To Whom Payable Original Original Present Balance Rate of Maturity Monthly Security Interest Amount Date Date Payment Past Due

Acct. # Acct. # Acct. # Acct. # Acct. # Acct. # Acct. # Acct. # Acct. #

$ $ $ $ $ $ $ $ $

$ $ $ $ $ $ $ $ $
Complete Address

$ $ $ $ $ $ $ $ $
% Owned *Military Service From To Service Disabled *Sex

MANAGEMENT (Proprietor, partners, officers, directors, all holders of outstanding stock ­100% of ownership must be shown.) Use separate sheet if necessary. Name and Social Security Number And Position/Title

Race *: Amer. Ind./Alaska Native

Black/Afr.-Amer.

Asian

Native Haw./Pacific Islander

White/Cauc.

Ethnicity *Hisp./Latino

Not Hisp./Latino

Service Disabled Race *: Amer. Ind./Alaska Native Black/Afr.-Amer. Asian Native Haw./Pacific Islander White/Cauc. Ethnicity *Hisp./Latino Not Hisp./Latino

Service Disabled Race *: Amer. Ind./Alaska Native Black/Afr.-Amer. Asian Native Haw./Pacific Islander White/Cauc. Ethnicity *Hisp./Latino Not Hisp./Latino

Service Disabled Race *: Amer. Ind./Alaska Native Black/Afr.-Amer. Asian Native Haw./Pacific Islander White/Cauc. Ethnicity *Hisp./Latino Not Hisp./Latino

*This data is collected for statistical purposes only. It has no bearing on the credit decision. Disclosure is voluntary. One or more boxes for race may be selected.

THE FOLLOWING EXHIBITS MUST BE COMPLETED WHERE APPLICABLE. ALL QUESTIONS ANSWERED ARE MADE A PART OF THE APPLICATION.
For Guaranty Loans please provide an original and one copy (Photocopy is Acceptable) of the Application Form and all Exhibits to the participating Lender. For Direct Loans submit one original copy of the application and Exhibits to SBA. 1.Submit SBA Form 912 (Statement of Personal History) for each type of individual that the Form 912 requires. 2. If your collateral consists of (A) Land and Building, (B) Machinery and Equipment, (C) Furniture and Fixtures, (D) Accounts Receivable, (E) Inventory, (F) Other, please provide an itemized list that contains serial and identification numbers for all articles that had an original value of greater than $5,000. Include a legal description of Real Estate offered as collateral. Label it Exhibit A. 3. Furnish a signed current personal balance sheet (SBA Form 413 may be used for this purpose) for each stockholder (with 20% or greater ownership), partner, officer, and owner. Include the assets and liabilities of the spouse and any close relatives living in the household. Also, include your Social Security Number. The date should be the same as the most recent business financial statement. Label it Exhibit B.
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4. Include the financial statements listed below: a, b, c for the last three years; also a, b, c, and d as of the same date, - current within 90 days of filing the application; and statement e, if applicable. Label it Exhibit C (Contact SBA for a referral if assistance with preparation is wanted.) All information must be signed and dated. a. Balance Sheet b. Profit and Loss Statement (if not available, explain why and substitute Federal income tax forms) c. Reconciliation of Net Worth d. Aging of Accounts Receivable and Payable (summary) e. Projection of earnings for at least one year where financial statements for the last three years are unavailable or when SBA requests them. 5. Provide a brief history of your company and a paragraph describing the expected benefits it will receive from the loan. Label it Exhibit D. 6. Provide a brief description similar to a resume of the education, technical and business background for all the people listed under Management. Label it Exhibit E.
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7. Submit the name, addresses, tax I.D. number (EIN or SSN), and current personal balance sheet(s) of any co-signers and/or guarantors for the loan who are not otherwise affiliated with the business. Exhibit F. 8. Include a list of any machinery or equipment or other non-real estate assets to be purchased with loan proceeds and the cost of each item as quoted by the seller. Include the seller's name and address. Exhibit G. 9. Have you or any officer of your company ever been involved in bankruptcy or insolvency proceedings? If so, please provide the details as Exhibit H. If none, check here: [ ]Yes [ ]No 10. Are you or your business involved in any pending lawsuits? If yes provide the details. Exhibit I. If none, check here: [ ]Yes [ ]No 11.Do you or your spouse or any member of your household, or anyone who owns, manages, or directs your business or their spouses or members of their households work for the Small Business Administration, Small Business Advisory Council, SCORE or ACE, any Federal Agency, or the participating lender? If so, please provide the name and address of the person and the office where employed. Label this Exhibit J. If none, check here: [ ] 12. Does your business, its owners or majority stockholders own or have a controlling interest in other businesses? If yes, please provide their names and the relationship with your company along with financial data requested in question 4. Label this Exhibit K. 13. Do you buy from, sell to, or use the services of any concern in which someone in your company has a significant financial interest? If yes, provide details on a separate sheet of paper labeled Exhibit L. 14. If your business is a franchise, include a copy of the franchise agreement and a copy of the FTC disclosure statement supplied to you by the Franchisor. Label this Exhibit M. CONSTRUCTION LOANS ONLY 15. Include as a separate exhibit the estimated cost of the project and a statement of the source of any additional funds. Label this Exhibit N. 16. Provide copies of preliminary construction plans and specifications. Label this as Exhibit 0. Final plans will be required prior to disbursement. EXPORT LOANS

AGREEMENTS AND CERTIFICATIONS
Agreements of non-employment of SBA Personnel: I agree that if SBA approves this loan application I will not, for at least two years, hire as an employee or consultant anyone that was employed by the SBA during the one year period prior to the disbursement of the loan. Certification: I certify: (a) I have not paid anyone connected with the Federal Government for help in getting this loan. I also agree to report to the SBA office of the Inspector General, Washington, DC 20416 any Federal Government employee who offers, in return for any type of compensation, to help get this loan approved. (b) All information in this application and the Exhibits are true and complete to the best of my knowledge and are submitted to SBA so SBA can decide whether to grant a loan or participate with a lending institution in a loan to me. I agree to pay for or reimburse SBA for the cost of any surveys, title or mortgage examinations, appraisals, credit reports, etc., performed by non-SBA personnel provided I have given my consent(c) I understand that I need not pay anybody to deal with SBA. I have read and understand SBA Form 159 which explains SBA policy on Agents and their fees and have submitted an SBA Form 159 completed by the Agent and myself for each fee covered by SBA Form 159. (d) As consideration for any Management, Technical, and Business Development Assistance that may be provided, I waive all claims against SBA and its consultants. (e) I authorize the SBA's Office of Inspector General 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. If you knowingly make a false statement or overvalue a security to obtain a guaranteed loan from SBA, you can be fined up to $10,000 and/or imprisoned for not more than five years under 18 USC 1001; if submitted to a Federally insured institution, under 18 USC 1014 by Imprisonment of not more than twenty years and/or a fine of not more than $1,000,000 If Applicant is a proprietor or general partner, sign below.

By: 17. Does your business currently export, or will it start exporting, pursuant to this loan (if approved) ? Check here: [ ]Yes [ ]No

If Applicant is a Corporation, sign below:

18. If you answered yes to item 17, what is your estimate of the total export sales this loan would support? $ _____
19. Would you like information on Exporting? Check here: [ ]Yes [ ]No _ COUNSELING/TRAINING 20. Have you received counseling or training from SBA (e.g., SCORE, ACE, SBDC, WBC, etc.) ? Check here: [ ]Yes [ ]No

Corporate Name and Seal

Date

By: Signature of President

Attested by: Signature of Corporate Secretary

SUBMIT COMPLETED APPLICATION TO LENDER OF CHOICE.

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APPLICANT'S CERTIFICATION
By my signature, I certify that I have read and received a copy of the "STATEMENTS REQUIRED BY LAW AND EXECUTIVE ORDER" which was attached to this application. My signature represents my agreement to comply with the approval of my loan request and to comply, whenever applicable, with the hazard insurance, lead-based paint, civil rights or other limitations in this notice. Each Proprietor, each General Partner, each Limited Partner or Stockholder owning 20% or more, each Guarantor, and the spouse, when applicable, of each of these must sign. Each person should sign only once. Business Name:

By: Signature and Title Guarantors:

Date

Signature and Title

Date

Signature and Title

Date

Signature and Title

Date

Signature and Title

Date

Signature and Title

Date

Signature and Title

Date

Signature and Title

Date

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PLEASE READ, DETACH, AND RETAIN FOR YOUR RECORDS
STATEMENTS REQUIRED BY LAW AND EXECUTIVE ORDER

Federal executive agencies, including the Small Business Administration (SBA), are 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, and they are contained in Parts 112, 113, 116, and 117, Title 13, Code of Federal Regulations Chapter 1, or Standard Operating Procedures. 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. Privacy Act (5 U.S.C. 552a) A person can request to see or get copies of any personal information that SBA has in his or her file when that file is retrievable 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. In making loans pursuant to section 7(a)(6) of the Small Business Act (the Act), 15 USC Section 636(a)(6), SBA is required to have reasonable assurance that the loan is of sound value and will be repaid or that it is in the best interest of the Government to grant the assistance requested. 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). 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). 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 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, including business credit reports on the small business borrower and consumer credit reports and scores on the principals of the small business and guarantors on the loan for purposes of originating, servicing, and liquidating small business loans and for purposes of routine periodic loan portfolio management and lender monitoring. See, 69 F.R. 58598, 58617 (and as amended from time to time) for additional background and other routine uses.

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Right to Financial Privacy Act of 1978 (12 U.S.C. 3401) This is notice to you as required by the Right of 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 guarantee. 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 accesses. 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. 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 future financial assistance from SBA under any program, including disaster assistance. Executive Orders -- Floodplain Management and Wetland Protection (42 F.R. 26951 and 42 F.R. 26961) The SBA discourages any 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 in future floods. 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. In some instances the business can be forced to cease operations or be prevented from starting operations in a new facility. Therefore, in some instances 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 borrower is a certification that the OSA requirements that apply to the borrower's business have been determined and the borrower to the best of its knowledge is in compliance. 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 that 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. The Federal agency that administers compliance with this law concerning this creditor is the Federal Trade Commission, Equal Credit Opportunity, Washington, D.C. 20580.

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Executive Order 11738 -- Environmental Protection (38 C.F.R. 25161) 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 environmental protection legislation. SBA must, therefore, impose conditions on some loans. By acknowledging receipt of this form and presenting the application, the principals of all small businesses borrowing $100,000 or more in direct funds stipulate to the following: 1. That any facility used, or to be used, by the subject firm is not cited on the EPA list of Violating Facilities. 2. That subject firm will comply with all the requirements of Section 114 of the Clean Air Act (42 U.S.C. 7414) and Section 308 of the Water Act (33 U.S.C 1318) relating to inspection, monitoring, entry, reports and information, as well as all other requirements specified in Section 114 and Section 308 of the respective Acts, and all regulations and guidelines issued thereunder. 3. That subject firm will notify SBA of the receipt of any communication from the Director of the Environmental Protection Agency indicating that a facility utilized, or to be utilized, by subject firm is under consideration to be listed on the EPA List of Violating Facilities. 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 aggressively collect 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: - Report the status of your loan(s) to credit bureaus - Hire a collection agency to collect your loan - Offset your income tax refund or other amounts due to you from the Federal Government - Suspend or debar you or your company from doing business with the Federal Government - Refer your loan to the Department of Justice or other attorneys for litigation - Foreclose on collateral or take other action permitted in the loan instruments. 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 (Pub. L. 99-603). 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 or 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 leadbased 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 (13 C.F.R. 145) 1. The prospective lower tier participant certifies, by submission of this loan application, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. 2. Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participants shall attach an explanation to the loan application.
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