Sba Form 159 Fee Disclosure Form And Compensation Agreement Page 2
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3Loan applicant name:
Loan applicant business name (if any):
System of Records Notification: Information obtained from this form is part of the Agency’s Privacy Act Systems of
Records, Loan Systems (“SOR 21”) and may become part of SBA’s System of Records for Suspension and Debarment
Files (“SOR 36”). As such this record and the information contained therein may be used, disclosed, or referred for the
following purposes, among others:
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To the Federal, State, local or foreign agency or professional organization which investigates, prosecutes or
enforces violations of statutes, rules, regulations or orders, or which undertakes procurement of goods or services,
when SBA determines that disclosure will promote programmatic integrity or protect the public interest.
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To SBA employees, contractors, interns, volunteers, and other regulators or legal authorities for the review of
Loan Agent fees and activities and for the review of loans generated by Loan Agents (e.g. for performance and
other trends).
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To GSA and the public for publication of Loan Agent suspensions, revocations, debarments, other enforcement
actions, and exclusions in the System Awards Management’s (SAM) Excluded Parties List System (EPLS) or any
successor system and on the SBA website consistent with Executive Order 12549 and other applicable law.
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To SBA employees, contractors, interns, volunteers and other regulators for regulatory purposes.
(See 77 FR 61467 (October 9, 2012), 77 FR 15835 (March 16, 2012), 74 FR 14890 (April 1, 2009) and as amended from
time to time for additional routine uses.)
Agent’s Agreement and Certifications: By signing this form, the undersigned Agent agrees that it has not and will
not directly or indirectly charge or receive any payment in connection with the application for or making of the SBA
loan except for services actually performed on behalf of Applicant and identified in this form. The undersigned Agent
certifies that the information provided in this form accurately describes the type of services it has provided to the
Applicant and that the compensation described in this form is the only compensation that has been charged to or
received from the Applicant or that will be charged to the Applicant for services covered by this form. The
undersigned Agent further certifies that neither it nor any of the principals of its organization are presently debarred,
suspended, proposed for debarment, declared ineligible or voluntarily excluded from participation in this transaction
by any Federal department or Agency. WARNING: False certifications can result in criminal prosecution under
18 U.S.C. § 1001 and other penalties provided under law.
Type of agent:
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Lender compensated by
Broker or Referral
Independent loan
Other (describe):
applicant for loan
agent employed by
packager
packaging services
applicant
Type of services agent provided to applicant:
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Loan packaging
Financial statements
Broker or Referral
Other (describe):
specifically for the
services paid by
application
applicant
Total compensation charged to applicant:
$________________________
If the amount exceeds $2,500: For the entire compensation charged, attach a separate schedule itemizing 1)
the services performed; and 2) the hourly rate and the number of hours billed for that service. An itemization
describing the services actually performed is required even if the compensation charged is on a percentage
basis.
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