SEDI CERTIFICATION

SEDI Certification (if applicable):

Legal name of the Beneficiary: _________________________________

Client Certification Related to Business Enterprises Owned and Controlled by Socially and Economically Disadvantaged Individuals (SEDI-Owned Businesses).

This certification is used by ESD to obtain the applicable SEDI-owned business certification. This transaction is supported with funding provided through the State Small Business Credit Initiative (SSBCI), a federal program that supports small business lending and investment programs in states, the District of Columbia, territories, and Tribal governments (collectively known as participating jurisdictions). SSBCI programs are designed to expand access to capital, promote economic resiliency, and create new jobs and economic opportunity. SSBCI provides funding for participating jurisdictions to support businesses owned and controlled by socially and economically disadvantaged individuals (SEDI-owned businesses).“Socially and Economically Disadvantaged Individual – Owned Business (SEDI)” shall have the meaning of:

1 A business enterprise that certifies that they are owned and controlled by individuals who have had their access to credit on reasonable terms diminished as compared to others in comparable economic circumstances, due to their (1) membership of a group that has been subjected to racial or ethnic prejudice or cultural bias within American society; (2) gender; (3) veteran status; (4) limited English proficiency; (5) physical handicap; (6) long-term residence in an environment isolated from the mainstream of American society; (7) membership of a federally or state recognized Indian tribe; (8) long-term residence in a rural community; (9) residence in a U.S. territory; (10) residence in a community undergoing economic transitions (including communities impacted by the shift towards a net-zero economy or deindustrialization); or (11) membership of another “underserved community” as defined in Executive Order 13985;

2 A business enterprise that certified that they are owned and controlled by individuals whose residences are in CDFI Investment Areas, as defined in 12 C.F.R. § 1805.201(b)(3)(ii);

3. A business enterprise that certifies that they will operate a location in a CDFI Investment Area, as defined in 12 C.F.R. § 1805.201(b)(3)(ii); or

4 A business enterprise that is located in a CDFI Investment Areas, as defined in 12 C.F.R.

§ 1805.201(b)(3)(ii).

“Very Small Business shall be a business with fewer than 10 employees at the time of the loan, investment, or other credit/ equity support and includes independent contractors and sole proprietors.

This certification provides documentation that an SSBCI loan supported a SEDI-owned business. * The information collected from this certification can only be used for purposes of the SSBCI program and must not be used for any other purposes (e.g., marketing, sale to third parties). The information collected must also not be used in a manner that violates any applicable antidiscrimination laws, including, but not limited to, the laws specified in Section IX.b of the Capital Program Policy Guidelines (Compliance with Civil Rights Requirements). The Grantee may identify all categories in groups (1) through (3) below that apply, including all subcategories in group (1) that apply.

Legal name of Beneficiary:

The client hereby certifies to the Grantor or investor that it is a:

1. Business enterprise that is owned and controlled** by individuals who have had their access to credit on reasonable terms diminished as compared to others in comparable economic circumstances, due to their:

☐ membership of a group that has been subjected to racial or ethnic prejudice or cultural bias within American society;

☐ gender;

☐ veteran status;

☐ limited English proficiency;

☐ disability;

☐ long-term residence in an environment isolated from the mainstream of American society; ☐ membership of a federally or state-recognized Indian Tribe;

☐ long-term residence in a rural community;

☐ residence in a U.S. territory;

☐ residence in a community undergoing economic transitions (including communities impacted by the shift towards a net-zero economy or deindustrialization); or ☐ membership of another underserved community***.

2. ☐ Business enterprise that is owned and controlled by individuals whose residences are in CDFI Investment Areas, as defined in 12 C.F.R. § 1805.201(b)(3)(ii). **** Individual(s)’ Address(es) in CDFI Investment Areas: ______________________________

3 ☐ Business enterprise that will build, open, or operate a location in a CDFI Investment Area, as defined in 12 C.F.R. § 1805.201(b)(3)(ii). Business Address in CDFI Investment Area: ______________________________________________________________________________

* SSBCI funds count toward fulfilling the “expended for” requirement for the $1.5 billion SEDI allocation and toward qualifying for initial eligible amounts under the $1.0 billion SEDI incentive allocation if the SSBCI funds have been expended for loans, investments, or other credit or equity support to any of the four groups of businesses set forth in Section IV.a of the SSBCI Capital Program Policy Guidelines. While a participating jurisdiction may reasonably identify group (4) businesses (i.e., those located in Community Development Financial Institution (CDFI) Investment Areas) based on businesses’ addresses from the relevant loan, investment, and credit or equity support applications, certification is required with regard to groups (1) through (3).

** The term “owned and controlled” means, if privately owned, 51 percent is owned by such individuals; if publicly owned, 51 percent of the stock is owned by such individuals;

and in the case of a mutual institution, a majority of the board of directors, account holders, and the community of which the institution services is predominantly comprised of such individuals *** “Underserved communities” are populations sharing a particular characteristic, as well as geographic communities, that have been systematically denied a full opportunity to participate in aspects of economic, social, and civic life, as exemplified by the list in the definition of equity. Equity is consistent and systematic fair, just, and impartial treatment of all individuals, including individuals who belong to underserved communities that have been denied such treatment, such as Black, Latino, and Indigenous and Native American persons, Asian Americans and Pacific Islanders and other persons of color; members of religious minorities; lesbian, gay, bisexual, transgender, and queer (LGBTQ+) persons;

persons with disabilities; persons who live in rural areas; and persons otherwise adversely affected by persistent poverty or inequality.

**** Treasury has provided a mapping tool for the Grantee or investee to use to identify whether the relevant address is in a CDFI Investment Area at https://home.treasury.gov/policy-issues/small-business-programs/state-small-business-credit-initiative-ssbci/2021-ssbci/cdfi-fund-investment-areas. For each calendar year, Treasury will use the list of CDFI Investment Areas identified by the CDFI Fund as of January 1 of the calendar year. If the CDFI Fund’s list is updated during that calendar year, the new list will not be adopted for purposes of SSBCI until the next calendar year, thus providing advance notice to jurisdictions. Further, Treasury has determined that American Samoa, Guam, the Northern Mariana Islands, and the U.S. Virgin Islands in their entirety constitute CDFI Investment Areas for purposes of the SSBCI, because each of these territories has a poverty rate of at least 20 percent.

The undersigned is an authorized representative of the Beneficiary.

Signature:

____________________________________________________________________________ Name:

Title:

______________________________________________________________________________Date:

Capital Access New York State Demographic Data Form

Legal Name of Borrower: __________________________________________ Filling out this form and providing demographic information is optional. Applicants are not required to provide the requested information but are encouraged to do so. The entity collecting this information cannot discriminate based on whether an applicant provides this information or based on any information provided on this form. If you decline to provide this information, it will not adversely affect your application.

Applicants are encouraged to answer all the questions below.

Ethnicity of applicant [select one]

☐ Hispanic or Latino/a ☐ Not Hispanic or Latino/a ☐ Prefer not to respond

Race of applicant [select all that apply]

☐ American Indian or Alaska Native

☐ Black or African American

☐ Asian

☐ Chinese ☐ Filipino ☐ Japanese ☐ Korean ☐ Vietnamese ☐ Asian Indian ☐ Bangladeshi

☐ Pakistani ☐ Hmong ☐ Cambodian ☐ Thai

☐ Pacific Islander

☐ Native Hawaiian ☐ Guamanian and Chamorro ☐ Samoan

☐ Other Asian or Pacific Island Group

☐ White

☐ Middle Eastern or North African

North African: ☐ Egyptian ☐ Moroccan ☐ Algerian ☐ Tunisian ☐ Libyan ☐ Other Major NA Group

Middle Eastern: ☐ Yemeni ☐ Iranian ☐ Palestinian ☐ Iraqi ☐ Lebanese ☐ Israeli ☐

Syrian ☐ Armenian ☐ Saudi ☐ Other Major ME Group

Other Middle Eastern and North African: ☐ Amazigh ☐ Syriac ☐ Other Transnational

Indigenous MENA Community ☐ Other Transnational MENA Group

☐ Prefer not to respond

What is your current gender? [Select one] ☐ Woman

☐ Man

☐ Nonbinary

☐ I use a different term: _________________

☐ I don’t know

☐ Prefer not to answer

Do you consider yourself to be transgender? [Select one] ☐ Yes

☐ No

☐ I don’t know

☐ Prefer not to respond

Sexual Orientation – Which of the following best represents how you think of yourself?

[Select one] ☐ Gay or Lesbian

☐ Bisexual

☐ Straight, that is, not Gay or Lesbian

☐ I use a different term: _______________________

☐ I don’t know

TECHNICAL ASSISTANCE GRANT PROGRAM

CLIENT INTAKE FORM

TA PROVIDER:

Client Basics Intake Date: mm/dd/yyyy Time Spent with Client: (hours and minutes)

Business Information

Company Name Tax ID Number

Stage of Business ☐ Thinking of Starting a business ☐ In process of starting or acquiring a business ☐ Own a business in operation less than one year

☐ Own a business in operation 1-5 years

☐ Own a business in operation over 5 years

Form of Business ☐ Sole Proprietorship Using Own Name ☐ Sole Proprietorship Filed DBA ☐ Partnership ☐ Corporation – regular ☐ S-Corporation ☐ Corporation – LLC ☐ Unknown at this time

Type of Business ☐ Retail ☐ Service ☐ Manufacturing ☐ Construction ☐ Finance, Insurance, Real

Estate ☐ Wholesale Distribution ☐ Agriculture ☐ Unknown at this Time ☐ Other: ___

Usable Business Plan ☐ Yes ☐ No ☐ Partial or needs work

Client Information

First Name

Last Name

Address 1

Address 2

City

State

Zip

County

Telephone Number

Cell Phone

Fax Number

Email

Website Gender ☐ F (Female) ☐ M (Male) ☐ X or Other (X‐Gender or Gender Not Listed)

Age ☐ 18-24 ☐ 25-30 ☐ 31-40 ☐ 41-50 ☐ 51-60 ☐ 61+

Highest Education Attained ☐ Grade School ☐ Junior High School ☐ High School / GED ☐ Trade School 2 / Year College ☐ 4 Year College / University Graduate School ☐ Doctorate

Other Business Information

Business Facility ☐ Home Based ☐ Own Outside Facility ☐ Rent Outside Facility

Income Generated Is ☐ Main Source of Income ☐ Supplementary Income

Date Business Started mm/dd/yyyy First Sale Date mm/dd/yyyy

Gross Revenues/Sales $ For most recent FULL Business Year

Number of Owners

Designation Group/Status

☐ Veteran owned or controlled business

☐ Dislocated Worker

☐ Disabled Individual ☐ MOB (Self-Declared Minority Owned Business

☐ WOB (Self- Declared Women Owned Business)

☐ SEDI-

owned business (self-certified)

☐ Not a SEDI Business ☐ Very Small Business

☐ Certified SEDI-owned business

Employment Status

☐ Employed Full Time

☐ Employed Part Time

☐ Self Employed Full Time

☐ Self Employed Part Time

☐ Displaced Homemaker

☐ Unemployed ☐ Public Assistance ☐ Retired

Race of Principal Owner (SSBCI)

☐ American Indian or Alaska Native

☐ Black or African American

☐ Asian- Vietnamese

☐ White

☐ Asian-Indian ☐ Native Hawaiian or Other Pacific Islander

☐ Asian (Other) ☐ Prefer not to respond

☐ Asian-Chinese ☐ Native Hawaiian or Other Pacific Islander – Guamanian or Chamorro

☐ Asian-Korean ☐ Native Hawaiian or Other Pacific Islander – Pacific Islander (Other)

☐ Asian-Filipino ☐ Native Hawaiian or Other Pacific Islander – Native Hawaiian

☐ Prefer not to respond

☐ The business did not answer

☐ Asian-Japanese ☐ Native Hawaiian or Other Pacific Islander – Samoan

Ethnicity of Principal Owner (NYS) ☐ American Indian or Alaska Native ☐ Black or African

American ☐ White ☐ Prefer Not to

Respond Asian:

☐ Chinese ☐ Filipino ☐ Japanese ☐ Korean ☐ Vietnamese ☐ Asian Indian ☐ Bangladeshi ☐ Pakistani ☐ Hmong ☐ Cambodian ☐ Thai

Pacific Islander:

☐ Pacific Islander ☐ Native Hawaiian ☐ Guamanian and

Chamorro ☐ Samoan

☐ Other Asian or Pacific Islander Group

☐ Middle Eastern or North African

North African:

☐ Egyptian ☐ Moroccan ☐ Algerian ☐ Tunisian ☐ Libyan ☐ Other Major

NA Group

Middle Eastern:

☐ Yemeni ☐ Iranian ☐ Palestinian ☐ Iraqi ☐ Lebanese ☐ Israeli ☐ Syrian ☐ Armenian ☐ Saud ☐ Other Major ME

Group

Other Middle Eastern and Northern African:

☐ Amazigh ☐ Syriac ☐ Other

Transnational Indigenous

MENA

Community

☐ Other Transnational MENA Group

Middle Eastern or African Ancestry:

☐ Middle Eastern or North African

☐ Not Middle Eastern or North African

☐ Prefer not to respond

Race of Principal Owner (NYS)

☐ Hispanic or Latino/a ☐ Not Hispanic or Latino/a

☐ Prefer not to respond

Gender of Principal Owner (NYS)

☐ Woman ☐ Man ☐ Nonbinary ☐ I use a different term:

☐ I don’t know ☐ Prefer not to respond

Do you consider yourself a to be transgender?

☐ Yes ☐ No ☐ I don’t know

Sexual Orientation of Principal Owner (NYS)

☐ Gay or lesbian ☐ Bisexual ☐ Straight, not gay or lesbian

☐ Something else

Type of Provision What type of services were provided?

☐ Legal ☐ Accounting ☐ Financial Advisory Services

Briefly describe the services provided. *

SSBCI Programs Track One: General SSBCI Programs

☐ Capital Access Program ☐ Small Business Revolving Loan

Fund ☐ New York Forward Loan Fund ☐ Capital Project Loan Fund ☐ Main Street Capital Loan Fund ☐ Other Special Projects

Track Two: Contractor Financing Program and/or Surety Bond Associate Program ☐ Contractor Financing Program ☐ Surety Bond Assistance Program

Does the Business have a history working on NYS based contract?

☐ Yes ☐ No

If yes, please list the project name(s) and agencies?

Comments (TA Provider):

* Please refer to the tool tips below when describing services provided.

☐ I don’t know ☐ Prefer not to respond

☐ I use a different term: