Loan Application Checklist, Small Business Loan Intake Form Etc. Page 11

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(5) Are you presently debarred, suspended, proposed for debarment, declared ineligible, or

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voluntarily excluded from participation in this transaction by any Federal department or agency?Yes

... No

(6) If you are at least a 50% or more owner of the applicant business, are you more than 60 days

delinquent on any obligation to pay child support arising under an administrative order, court

order, repayment agreement between the holder and a custodial parent, or repayment agreement

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between the holder and a state agency providing child support enforcement services? .................. Yes

... No

If “YES” to Question 1, the loan request is ineligible for SBA assistance. If there is a “YES” response to

Question 2 or 3, you must complete SBA Form 912 and furnish details on a separate sheet, including dates,

location, fines, sentences, whether misdemeanor or felony, dates of parole/probation, unpaid fines or penalties,

name(s) under which charged, and any other pertinent information. If “YES” to Questions 2 or 3, the lender

will be required to conduct a background check and make a character determination in accordance with the

procedures described in SOP 50 10 5. If “YES” to Question 3 and you are currently on parole or probation

(including probation before judgment), the loan request is ineligible for SBA assistance. If the charge resulting

in a “YES” was a single misdemeanor that was subsequently dropped without prosecution, you must provide

documentation from the appropriate court or prosecutor’s office along with the completed Form 912.

If “YES” to Questions 4, 5 or 6, this application may not be submitted to SBA under any delegated or

expedited processing method, but must be submitted to the Standard 7(a) Loan Guaranty Processing Center

(LGPC) for non-delegated processing. The only exception is an application that was declined under a 7(a)

Small Loan due to the applicant’s credit score may be submitted under SBA Express procedures. Note: This

does not mean that your loan will be denied, only that your lender will need to use different SBA procedures

to process the loan.

....

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(7) Are you a U.S. Citizen? ................................................................................................................... Yes

....

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If “No,” are you a Lawful Permanent resident alien? ...................................................................... Yes

Provide Alien Registration Number ____________________

(8) Are any of your business’ products or services exported or do you plan to begin exporting as a



result of this loan? ............................................................................................................................ Yes

... No

If “”Yes,” provide the estimated total export sales this loan will support: $________________________

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(9) Is your business a franchise? .......................................................................................................... Yes

... No

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(10) Does the Applicant business have any Affiliates? ....................................................................... Yes

... No

Affiliation exists when one individual or entity controls or has the power to control another or when a third

party or parties control or have the power to control both. SBA considers factors such as ownership,

management previous relationships with or ties to another entity, and contractual relationships when

determining whether affiliation exists. The complete definition of affiliation is found at 13 CFR 121.103. (See

also, 13 CFR 121.107 and 121.301.) An “Affiliate” includes, for example: (1) a parent company; (2)

subsidiaries and other companies that are owned or controlled by the Applicant; (3) companies in which an

officer, director, general partner, managing member or party owning 20% or more is also an officer, director,

general partner, managing member or 20% or greater owner of the Applicant; (4) companies or individuals with

unexercised options to own 50% or more of the Applicant’s stock; and (5) companies that have entered into

agreements to merge with the Applicant.

If answered “yes,” attach a listing of all Affiliates to this form.

(11) Have you, the Applicant, its Affiliates, or any business owned or controlled by you or any

Associate ever obtained a direct or guaranteed loan from SBA or any other Federal agency or

been a guarantor on such a loan? (This includes student loans and disaster loans.) ................ Yes  ... No 

(a) If you answered “Yes” to Question 11, is any of the financing currently delinquent?............Yes ...No 

(b) If you answered “Yes” to Question 11, did any of this financing ever default and cause a

loss to the Government? ..................................................................................................... ....... Yes  ... No 

(12) What is the existing number of employees currently employed by the business? _____________

(13) Number of jobs to be created as a result of the loan? _____________ Number of jobs that will be retained as a

result of the loan that would have been lost otherwise?_____________

(14) Have you or the Applicant used (or intend to use) a packager, broker, accountant, lawyer, etc.to assist

in (a) preparing the loan application or any related materials and/or (b) referring the loan to the

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lender? ........................................................................................................................................... Yes

... No

If answer is “Yes,” a SBA

Form 159

7(a) will need to be completed by the Applicant and the lender.

SBA Form 1919 (Revised 4/14)