Loan Application Checklist, Small Business Loan Intake Form Etc. Page 12
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(15) Will more than $10,000 of the loan proceeds be used for construction? ...................................... Yes
... No
If answer is “Yes,” a SBA
Form 601
will need to be completed.
(16) Are any of the Applicant’s revenues derived from gambling or from the sale of products or services, or the
presentation of any depiction, displays or live performances, of a prurient sexual nature? ......... Yes
... No
... No
(17) Is the loan request for a Community Advantage Pilot Program loan?
Yes
If answer is “Yes,” a SBA Form 2449, Community Advantage Addendum will need to be completed.
SBA may not provide financial assistance to an applicant where there is any appearance of a conflict of interest with
an SBA or other governmental employee. If any of the questions below are answered “False”, this application may
not be submitted under any delegated or expedited processing method, but must be submitted to the LGPC for non-
delegated processing. 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.
(18) No SBA employee, or the household member (see definition at * below) of an SBA employee, is a sole
proprietor, partner, officer, director, or stockholder with a 10 percent or more interest, of the Applicant. [13 CFR
105.204]
True____ False_____
(19) No former SBA employee, who has been separated from SBA for less than one year prior to the request for
financial assistance, is an employee, owner, partner, attorney, agent, owner of stock, officer, director, creditor or
debtor of the Applicant. [13 CFR 105.203]
True____ False_____
(20) No member of Congress, or an appointed official or employee of the legislative or judicial branch of the Federal
Government, is a sole proprietor, general partner, officer, director, or stockholder with a 10 percent or more
interest, or household member of such individual, of the Applicant.
[13 CFR 105.301(c)]
True____ False_____
(21) No Government employee having a grade of at least GS-13 or higher is a sole proprietor, general partner,
officer, director, or stockholder with a 10 percent or more interest, or a household member of such individual, of
the Applicant. [13 CFR 105.301(a)]
True____ False_____
(22) No member or employee of a Small Business Advisory Council or a SCORE volunteer is a sole proprietor,
general partner, officer, director, or stockholder with a 10 percent or more interest, or a household member of
such individual, of the Applicant. [13 CFR 105.302(a)]
True____ False_____
* A “household member” of an SBA employee includes: a) the spouse of the SBA employee; b) the minor children
of said individual; and c) the blood relatives of the employee, and the blood relatives of the employee’s spouse
who reside in the same place of abode as the employee.[13 CFR 105.201(d)]
SBA Form 1919 (Revised 4/14)
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