B05_73351018R0010_Attachment_6_SBA_Form_5C_Loan_Application.pdf

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INFORMATION ABOUT THE APPLICANT(S)

Primary Applicant Joint Applicant

CONTACT INFORMATION

DAMAGED PROPERTY ADDRESS additional damaged properties added in "additional comments" section Is this property your Primary Residence?

If No, please select from the list below:

Type of Damage:

INCOME INFORMATION

Joint Applicant Primary Applicant Note: Include all reoccurring income from all sources such as employment, self-employment, part-time work, social security, retirement income, disability income, interest income, child support, alimony, etc.

Do not include one-time or non-reoccurring income.

DAMAGED PROPERTY INFORMATION

Check your preferred method of contact:

MAILING ADDRESS

if different than the damaged property address.

Marital Status Are you a U.S. Citizen?

Check your preferred method of contact:

SBA Internal Use Only:

Are you an SBA Employee?

Marital Status Are you a U.S. Citizen?

Are you an SBA Employee?

Note: Include all reoccurring income from all sources such as employment, self-employment, part-time work, social security, retirement income, disability income, interest income, child support, alimony, etc.

Do not include one-time or non-reoccurring income. Do not include items covered by Primary Applicant Do you own or rent this property?

ARE YOU APPLYING FOR:

Date Received___________ Location_________By_____

DISASTER HOME / SOLE PROPRIETOR LOAN APPLICATION

OMB No. : 3245-0018 Expiration: xx/xx/xxxx U. S. Small Business Administration .\SBA seal for Form 5 and 5C.jpg SBA Form 5C (XX-XX) Ref SOP 50 30 Closest Relative Not Living With You:

Note: Please complete the section below if the amounts are NOT included in your mortgage payment:

Homeowner's Insurance Real Estate Taxes Condo/Townhome/HOA/Co-Op Fees per year per year per year Other Debt including auto payments, credit cards, installment loans, student loans, etc. Note: Only include debts that will last longer than 10 months.

Current Balance Name of Creditor

ASSETS

Pre-disaster values:

INSURANCE INFORMATION

Please check all insurance in force for the damaged property:

(describe)

OTHER DISASTER ASSISTANCE

Other than FEMA, have you received any grant award (i.e. city grants, county grants, state grants, etc.):

Monthly Payment Policy Type Insurance Company Name Policy Number Phone Number Amount Received

DISCLOSURES

The responses below apply to the Applicant and Joint Applicant, if any. Please explain any "Yes" responses on the last page.

Are you delinquent on any Federal taxes, Federal loans, Federal grants, or 60 days past due on any child support obligation?

Are you currently a defendant in any lawsuits or have pending judgements against you?

Are you presently, a) subject to an indictment, criminal information, arraignment, or other means by which formal criminal charges are brought in any jurisdiction; b) have you been arrested in the past six months for any criminal offense; c) for any criminal offense -other than a minor vehicle violation -- have you ever: 1) been convicted, 2) plead guilty, 3) plead nolo contendere, 4) been placed on pretrial diversion, or 5) been placed on any form of parole or probation (including probation before judgment)?

In the past year, have you been convicted of a felony committed in connection with a riot or civil disorder?

Are you engaged in the production or distribution of any product that has been determined to be obscene by a court of competent jurisdiction?

Are you currently suspended or debarred from contracting with Federal government or receiving Federal grants or loans?

Current Balance Monthly Payment/Rent 2nd Mortgage Holder Name (if applicable) Mortgage Holder or Landlord's Name (Primary Residence) Monthly Payment/Rent Current Balance

DEBTS

1.

2.

3.

4.

6.

7.

5.

Do you have federal loans, federally guaranteed loans, or previous SBA loans?

SBA Form 5C (XX-XX) Ref SOP 50 30

CONSENT

I authorize my insurance company, bank, financial institution, or other creditors to release to SBA all records and financial information necessary to process this application.

SBA has my permission, as required by the Privacy Act, to release any information collected in connection with this application to Federal, state, local, tribal or nonprofit organizations (e.g. Red Cross, Salvation Army, Mennonite Disaster Services, SBA Resource Partners) for the purpose of assisting me with my SBA application, evaluating my eligibility for additional disaster assistance, or notifying me of the availability of such assistance.

If my loan is approved, I may be eligible for additional funds to safeguard my property from damages similar to those caused by this disaster. Although it is not necessary for me to provide with my application, a description and cost estimate will be required prior to SBA approval of the mitigation measure.

I have received and read a copy of the "STATEMENTS REQUIRED BY LAWS AND EXECUTIVE ORDERS" which was attached to this application.

CERTIFICATION AS TO TRUTHFUL INFORMATION: By signing this application, you certify that all information in your application and submitted with your application is true and correct to the best of your knowledge, and that you will submit truthful information in the future.

WARNING: Whoever wrongfully misapplies the proceeds of an SBA disaster loan shall be civilly liable to the Administrator in an amount equal to one-and-one half times the original principal amount of the loan under 15 U.S.C. 636(b). In addition, any false statement or misrepresentation to SBA may result in criminal, civil or administrative sanctions including, but not limited to: 1) fines and imprisonment, or both, under 15 U.S.C. 645, 18 U.S.C. 1001, 18 U.S.C. 1014, 18 U.S.C. 1040, 18 U.S.C. 3571, and any other applicable laws; 2) treble damages and civil penalties under the False Claims Act, 31 U.S.C. 3729; 3) double damages and civil penalties under the Program Fraud Civil Remedies Act, 31 U.S.C. 3802; and 4) suspension and/or debarment from all Federal procurement and non-procurement transactions. Statutory fines may increase if amended by the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015.

Signature of Joint Applicant Signature of Applicant Date Date

ADDITIONAL COMMENTS

REPRESENTATIVE INFORMATION

If you have paid a representative (packager, attorney, accountant, etc.) to assist you in completing the application, please complete the section below:

Name and Address of representative:

Fee charged or agreed upon SBA Form 5C (XX-XX) Ref SOP 50 30 U.S. Small Business Administration

DISASTER HOME LOAN APPLICATION

If you have questions about this application or problems providing the required information, please contact our Customer Service Center at 1-800-659-2955 or disastercustomerservice@sba.gov. If more space is needed for any section of this application, please attach additional sheets.

SBA will contact you by phone or Email to discuss your loan request.

FILING REQUIREMENTS

REQUIRED FOR ALL LOAN APPLICATIONS:

■ Complete and sign this application form (SBA Form 5C)

■ Complete and sign the Tax Information Authorization (IRS Form 4506T) enclosed with this application. This income information, obtained from the IRS, will help us determine your repayment ability. U.S. Territories that have their own taxing authority outside of the IRS may require additional form(s) in order to obtain copies of their transcripts. The exact form(s) required will be determined at the onset of the declared disaster. All other filing requirements remain the same.

WHILE NOT NECESSARY TO ACCEPT YOUR APPLICATION, YOU MAY BE REQUIRED TO SUPPLY THE FOLLOWING INFORMATION TO PROCESS THE APPLICATION. IF REQUESTED, PLEASE PROVIDE WITHIN 7 DAYS OF THE INFORMATION REQUEST:

■ If any applicant has changed employment within the past two years, provide a copy of a current (within 1 month of the application date) pay stub for all applicants

■ If we need additional income information, you may be asked to provide copies of your Federal income tax returns, including all schedules

IF SBA APPROVES YOUR LOAN, WE MAY REQUIRE THE FOLLOWING ITEMS BEFORE LOAN CLOSING. WE WILL ADVISE YOU, IN WRITING, OF THE DOCUMENTS WE NEED.

■ If you own your residence, a COMPLETE legible copy of the deed, including the legal description of the property

■ If the damaged property is your primary residence, proof of residency at the damaged address

■ If you had damage to a manufactured home, a copy of the title. If you own the lot where the home is located, a COMPLETE legible copy of the deed, including the legal description of the property

■ If you have damage to an automobile or other vehicle, proof of ownership (a copy of the registration, title, bill of sale, etc.)

SBA Form 5C (XX-XX) Ref SOP 50 30

NOTE: PLEASE READ, DETACH AND KEEP FOR YOUR RECORDS

STATEMENTS REQUIRED BY LAWS AND EXECUTIVE ORDERS

To comply with legislation passed by the Congress and Executive Orders issued by the President, Federal executive agencies, including the Small Business Administration (SBA), must notify you of certain information. You can find the regulations and policies implementing these laws and Executive Orders in Title 13, Code of Federal Regulations (CFR), Chapter 1, or our Standard Operating Procedures (SOPs). In order to provide the required notices, the following is a brief summary of the various laws and Executive Orders that affect SBA's Disaster Loan Programs. A glossary of terms can be found at Disasterloan.SBA.GOV

FREEDOM OF INFORMATION ACT (5 U.S.C. 552)

This law provides, with some exceptions, that we must make records or portions of records contained in our files available to persons requesting them. This generally includes aggregate statistical information on our disaster loan programs and other information such as names of borrowers (and their officers, directors, stockholders or partners), loan amounts at maturity, the collateral pledged, and the general purpose of loans. We do not routinely make available to third parties your proprietary data without first notifying you, as required by Executive Order #12600, or information that would cause competitive harm or constitute a clearly unwarranted invasion of personal privacy.

Freedom of Information Act (FOIA) requests must describe the specific records you want. For information about the FOIA, contact the Chief, FOI/PA Office, 409 3rd Street, SW, Suite 5900, Washington, DC 20416, or by e-mail at foia@sba.gov.

PRIVACY ACT (5 U.S.C. § 552a)

Anyone can request to see or get copies of any personal information that we have in your file. Any personal information in your file that is retrieved by individual identifiers, such as name or social security number is protected by the Privacy Act, which means requests for information about you may be denied unless we have your written permission to release the information to the requestor or unless the information is subject to disclosure under the Freedom of Information Act. The Agreements and Certifications section of this form contains written permission for us to disclose the information resulting from this collection to state, local or private disaster relief services.

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, on the Disaster Loan Applicants and guarantors for purposes of originating, servicing, and liquidating Disaster loans. See, 69 F.R. 58598, 58617 (and as amended from time to time) for additional background and other routine uses.

Under the provisions of the Privacy Act, you are not required to provide social security numbers. (But see the information under Debt Collection Act below) We use social security numbers to distinguish between people with a similar or the same name for credit decisions and for debt collection purposes. Failure to provide this number may not affect any right, benefit or privilege to which you are entitled by law, but having the number makes it easier for us to more accurately identify to whom adverse credit information applies and to keep accurate loan records.

Note: Any person concerned with the collection, use and disclosure of information, under the Privacy Act may contact the Chief, FOI/PA Office, 409 3rd Street, SW, Suite 5900, Washington, DC 20416 or by e-mail at foia@sba.gov for information about the Agency's procedures relating to the Privacy Act and the Freedom of Information Act.

SBA Form 5C (XX-XX) Ref SOP 50 30

DEBT COLLECTION ACT OF 1982; DEFICIT REDUCTION ACT OF 1984; DEBT COLLECTION IMPROVEMENT ACT OF 1996 & other titles (31 U.S.C. 3701 et seq.)

These laws require us to aggressively collect any delinquent loan payments and to require you to give your taxpayer identification number to us when you apply for a loan. If you receive a loan and do not make payments when they become due, we may take one or more of the following actions (this list may not be exhaustive):

*Report the delinquency to credit reporting bureaus.

*Offset your income tax refunds or other amounts due to you from the Federal Government.

*Refer the account to a private collection agency or other agency operating a debt collection center.

*Suspend or debar you from doing business with the Federal Government.

*Refer your loan to the Department of Justice.

*Foreclose on collateral or take other actions permitted in the loan instruments.

*Garnish wages.

*Sell the debt.

*Litigate or foreclose.

RIGHT TO FINANCIAL PRIVACY ACT OF 1978 (12 U.S.C. § 3401 et seq.)

This notifies you, as required by the Right to Financial Privacy Act of 1978 (Act), of our right to access financial records held by financial institutions that were or are doing business with you or your business. This includes financial institutions participating in loans or loan guarantees.

The law provides that we may access your financial records when considering or administering Government loan or loan guaranty assistance to you. We must give a financial institution a certificate of our compliance with the Act when we first request access to your financial records. No other certification is required for later access. Our access rights continue for the term of any approved loan or loan guaranty. We do not have to give you any additional notice of our access rights during the term of the loan or loan guaranty.

We may transfer to another Government authority any financial records included in a loan application or about an approved loan or loan guaranty as necessary to process, service, liquidate, or foreclose a loan or loan guaranty. We will not permit any transfer of your financial records to another Government authority except as required or permitted by law.

CONSUMER CREDIT PROTECTION ACT (15 U.S.C. 1601 et seq.)

This legislation gives an applicant who is refused credit because of adverse information about the applicant's credit, reputation, character or mode of living an opportunity to refute or challenge the accuracy of such reports. Therefore, if we decline your loan in whole or in part because of adverse information in a credit report, you will be given the name and address of the reporting agency so you can seek to have that agency correct its report, if inaccurate. If we decline your loan in whole or in part because of adverse information received from a source other than a credit reporting agency, you will be given information but not the source of the report.

Within 3 days after the consummation of the transaction, any recipient of an SBA loan which is secured in whole or in part by a lien on the recipient's residence or household contents may rescind such a loan in accordance with "Regulation Z" of the Federal Reserve Board.

PLEASE NOTE: The estimated burden for completing this form is 1.25 hours. Your responses to the requested information are required in order to obtain a benefit under our Disaster Home Loan Program. However, you are not required to respond to any collection of information unless it displays a currently valid OMB approval number. If you have questions or comments concerning any aspects of this information collection, please contact the U.S. Small Business Administration Information Branch, 409 3rd Street, SW, Washington, DC 20416 and Desk Officer for SBA, Office of Management and Budget, Office of Information and Regulatory Affairs, 725 17th Street, NW, Washington, DC 20503. (3245-0018) PLEASE DO NOT SEND FORMS TO OMB.

SBA Form 5C (XX-XX) Ref SOP 50 30 9.0.0.2.20120627.2.874785 PDC Ext. 3003 Application Processing This is a draft of the future application.

Zachary Bradford SBA Form 5C - DCMS 2.0