Sba Form 1993 - Federal Agency Comment Form - Small Business Administration - 2013

Download a blank fillable Sba Form 1993 - Federal Agency Comment Form - Small Business Administration - 2013 in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Sba Form 1993 - Federal Agency Comment Form - Small Business Administration - 2013 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Federal Agency Comment Form

OMB Control #3245-0313

Small Business Administration – Office of the National Ombudsman

Exp. date 6/30/2016

Purpose: Small business owners may use this form to submit comments on Federal enforcement/compliance actions that

Case #:_________

they consider excessive or unfair. The National Ombudsman will use the information when it contacts the applicable

Federal agency for a review of the action.

Instructions

1. Complete, sign and date this form. (Signature not required if completed at ).

2. Provide a brief written statement on the reverse side regarding the specific enforcement or compliance action taken against your organization by the

federal agency.

3. Submit copies of substantiating documentation, such as correspondence, citation, or notice (Note: Can be submitted separately from this form by fax

or mail. Make sure to reference your name or company's name with this information).

4. If your comments concern the IRS, you must also submit a completed IRS Tax Information Authorization Form 8821, available at

(Can be sent by fax or mail).

5. Fax, e-mail or send this form and requested information to: (1) Fax: (202) 481-5719; (2) E-mail: Ombudsman@sba.gov; (3) Address: SBA,

Office of the National Ombudsman, 409 Third Street, SW, Washington, DC 20024. Telephone : (202) 205-2417.

Please Print

Organization/Company Name :

Address:

City:__________________________________________ State :__________________________

Zip:_____________________

Phone :

Fax :

E-mail:

Contact Name : Mr.

______________________________________ Title:____________________________________

Ms.

Please indicate your organization type:

Not

-for-Profit, Representing ________________________ Members

Small Business

___Association, Representing ______________ Members

Small Government (population of less than 50,000)

List the federal agency with which you are having a problem:

Federal Agency Name:

Agency Contact person:

Agency Office/Division:

Did the federal agency listed above inform you of your right to contact the SBA Office of the National Ombudsman?

Yes

If not, how did you learn about this office?

_______________________________________________________________________________________________

Confidentiality / Disclosure

The Small Business Regulatory Enforcement Fairness Act (SBREFA), allows you to keep your identity and other information private, and limit

its access only to the SBA (See 15 U.S.C. 657 (b) (2) (B)). However, by requesting confidentiality the federal agency may not have sufficient

information to investigate your specific problem, possibly delaying or preventing any potential resolution of your situation.

I request that my information be kept confidential.

Yes

(If yes, results may be limited.)

Signature:

Date :

Your signature authorizes the SBA Ombudsman to proceed on your behalf.

Pursue all legal options you believe are in your company’s best interest.

This process is not a substitute for legal action.

SBA FORM 1993 (3-13) Previous Editions Obsolete

Please Note: The estimated burden for completing this form is 45 minutes. You are not required to respond to this information collection if a valid OMB

approval number is not displayed. If you have any questions or comments concerning this estimate or other aspects of this information collection, please

contact the U. S. Small Business Administration, Chief, Administrative Information Branch, Washington, D.C . 20416 and/or Office of Management and

Budget, Clearance Officer, Paperwork Reduction Project (3245-0313), Washington, D.C. 20503. PLEASE DO NOT SEND FORMS TO OMB, as this will

delay action on your request for assistance.