ELIGIBILITY INFORMATION REQUIRED FOR PLP SUBMISSION Rev. 8/01/08

1.  Fill out all of this section. If a question in this section is
    answered "No," the loan is not eligible.

Applicant Name
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Lender Name
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Purpose of Loan
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Describe Type of Business
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Applicant is an operating business organized for profit, is located in
United States, has demonstrated a need for the

desired credit, and the desired credit is not otherwise available on
reasonable terms from non-Federal sources. YES\_\_\_NO\_\_\_

The products and/or services of the Applicant business are available to
the general public. YES\_\_\_NO\_\_\_

[Size]{.underline}

Primary industry of
Applicant\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_NAICS
Code of Applicant\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Average annual receipts of Applicant Business (excluding affiliates)
over last 3 completed fiscal
years\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

No. of employees of Applicant
Business\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, SBA size
standard for Applicant \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

The combined size calculation of applicant and its affiliates meets the
size standard for the applicant's primary industry

or the size standard for the primary industry of the applicant and its
affiliates, whichever is higher. YES\_\_\_ NO\_\_\_

If size standard is exceeded by no more than 25%, Applicant agrees to
use the assistance within a labor surplus area. YES\_\_\_NO\_\_\_

[CHECK IF APPLICABLE:]{.underline}

\_\_\_Applicant has possible affiliates. *If checked, provide the
following information in attachment to this form:*

\(1\) List possible affiliates, (2) discuss possible bases of
affiliation and (3) determine if affiliation exists.

If affiliation exists, the primary industry of the applicant and its
affiliates is \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. The NAICS Code is
\_\_\_\_\_\_\_\_\_.

The combined average annual receipts over last 3 completed fiscal years
or the number of employees for applicant and all affiliates
is\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (depending on the size standard
measure for the industry).

\_\_\_Applicant business has a franchise/license/dealer/jobber or
similar agreement.

*If checked, answer the following question:*

The SBA Franchise Registry lists the franchise/license/dealer/jobber or
similar agreement as an approved agreement. YES\_\_\_NO\_\_\_

> If "No," answer the following statement: You have made the
> determination that the applicant business has the right to profit and
> risk of loss commensurate with ownership and there are no excessive
> restraints on the sale of the franchise/license/dealer/jobber or
> similar interest. *[If "No," loan is not eligible.]{.underline}*
> YES\_\_\_NO\_\_\_

[Principals of the Applicant]{.underline}

Lender has assessed the liquid assets of the immediate family (including
spouse and dependent children) of each owner of 20% or more of the
equity of the Applicant (and of the Operating Company, if the Applicant
is an Eligible Passive Company) and determined that they do not exceed: 

-   for a financing package of \$250,000 or less, two times the total
    financing package or \$100,000, whichever is greater;

-   for a financing package between \$250,001 and \$500,000, one and
    one-half times the total financing package or \$500,000, whichever
    is greater;

-   for a financing package of more than \$500,000, one times the total
    financing package or \$750,000, whichever

is greater.  YES\_\_\_NO\_\_\_

No Associate (an officer, director, owner of more than 20 percent of the
equity, or key employee) of the Applicant is

incarcerated, on probation, on parole, or under indictment for a felony
or a crime of moral turpitude. YES\_\_\_NO\_\_\_

All owners of 20 percent or more of the Applicant (including a spouse
owning 5 percent or more when the combined ownership of both spouses is
20 percent or more) will guarantee the loan (except for ESOPs or
eligible 401(k)Trusts). YES\_\_\_NO\_\_\_

All principals of business are either U.S. citizens or non-U.S. citizens
whose INS status has been verified by the

lender. YES\_\_\_NO\_\_\_

[CHOOSE ONE:]{.underline}

\_\_\_\_The business is at least 51 percent owned by individuals who are
U.S. citizens and/or who have verified Lawful Permanent Resident (LPR)
status from INS and control the management and daily operations of the
business; OR

\_\_\_\_The business is at least 51 percent owned by aliens with a
verified status other than LPR, the lender has determined that continual
and consistent management of the business has been provided by a U.S.
citizen or by a verified LPR for at least one year and will continue
indefinitely AND U.S. collateral is pledged sufficient to pay the loan
in full at any time. (Businesses less than one year old do not meet
these requirements.)

# Terms of the Loan

The maturity of the loan does not exceed the maximum allowable by SBA
for the use of proceeds and is the

shortest appropriate term commensurate with repayment ability of the
Applicant. YES\_\_\_NO\_\_\_

SBA guaranty percentage does not exceed 85% for a loan of \$150,000 or
less and 75% for any other loan. YES\_\_\_NO\_\_\_

The amount of this loan does not exceed \$2 million. YES\_\_\_NO\_\_\_

[CHOOSE ONE:]{.underline}

\_\_\_\_\_\_\_\_The aggregate guaranty amount of the SBA portions for
this application and all outstanding 7(a) and 504 loans to Applicant and
its affiliates does not exceed \$1.5 million.

\_\_\_\_\_\_\_\_This is a working capital loan request to a borrower
that has an International Trade loan approved after 12/7/04. The
guaranty amount of this working capital loan does not exceed \$1.25
million, and the guaranty amount of the SBA portions of this working
capital loan, the IT loan and all other outstanding 7(a) and 504 loans
to Applicant and its affiliates does not exceed \$1.75 million.

The interest rate of the loan does not exceed the maximum amount
allowable based on loan maturity and size and if the interest rate is
variable, the base rate will be the prime rate in effect on the date SBA
receives an acceptable application, printed in the Wall Street Journal
or the SBA Optional Peg Rate published in the Federal Register.
YES\_\_\_NO\_\_\_

Applicant does not have a non-SBA-guaranteed loan made by any lender at
or about the same time for the same or similar

purpose as this PLP loan, with a lien position senior to this PLP loan
("Piggyback Loan"). YES\_\_\_NO\_\_\_

II. CHECK ANY ITEMS THAT ARE APPLICABLE IN THIS SECTION.

# Type of Business

> \_\_\_Applicant is or does one of the following: *[If checked, loan is
> not eligible]{.underline}.*

-   primarily engaged in the business of lending

-   a passive business that holds real and/or personal property to
    receive rent or lease income and does not provide sufficient
    services to deem it active and is not an Eligible Passive Company
    discussed below

-   bail bond company

-   life insurance company

-   does business in a foreign country (except for loan under the
    International Trade program)

-   pyramid sale distribution plan

-   any illegal activity

-   principally engaged in teaching, instructing, counseling or
    indoctrinating religion or religious beliefs, whether in a religious
    or secular setting.

-   consumer or marketing cooperative

-   earns 1/3 or more of its gross annual revenue from packaging SBA
    loans

-   derives directly or indirectly more than 5% of its gross revenue
    through the sale of products or services, or the presentation of any
    depiction or displays, of a prurient sexual nature or that presents
    any live performances of a prurient nature

-   primarily engaged in political or lobbying activities

-   a speculative business (such as oil wildcatting, mining and research
    & development)

\_\_\_Applicant is a pawn shop. *If checked, answer the following
question. [If "No" loan is not eligible]{.underline}.*

More than 50% of Applicant's income for the previous year was from the
sale of merchandise

rather than from interest on loans. YES\_\_\_NO\_\_\_

\_\_\_Applicant is a mortgage service company. *If checked, answer the
following question. [If "No" loan is not eligible]{.underline}.*

Any mortgage loans funded are sold within 14 days of loan closing.
YES\_\_\_NO\_\_\_

\_\_\_Applicant is a business that receives rental income (such as a
mini-warehouse or office suite). *If checked, answer the following
question. [If "No," loan is not eligible]{.underline}.*

> Applicant has provided adequate documentation that at least 50 percent
> of Applicant's revenue for the
>
> prior year is from services provided (not rental income); or if a new
> business, projections demonstrate that a least 50 percent of
> Applicant's revenue will be from services provided. YES\_\_\_NO\_\_\_

\_\_\_Applicant is a motel, trailer park, campground or similar type of
business. *If checked, answer the following question.*

> *[If "No" loan is not eligible]{.underline}.*

Applicant derives 50 percent or more of its gross annual income from
transients who stay for periods of

time not exceeding 30 days. YES\_\_\_NO\_\_\_

\_\_\_Any of gross annual revenue of Applicant business is derived from
gambling. *If checked, answer the*

*following question. [If "No" loan is not eligible]{.underline}.*

The revenue is from legal gambling activities and comprises 1/3 or less
of gross annual revenue of

Applicant business and the business is not a racetrack, casino or
otherwise have gambling as its

reason for being. YES\_\_\_NO\_\_\_

\_\_\_Applicant is a private club or business. *If checked, answer the
following question. [If "No" loan is not eligible]{.underline}.*

Business does not limit the number of memberships for reasons other than
capacity. YES\_\_\_NO\_\_\_

\_\_\_Applicant is a government-owned entity. *If checked, answer the
following question. [If "No" loan is not eligible]{.underline}.*

Applicant is business owned or controlled by a Native American tribe,
but is a separate legal

entity from the tribe. YES\_\_\_NO\_\_\_

\_\_\_Applicant is an Eligible Passive Company (EPC). *If checked, fill
in the blanks and answer the following questions[. If "No" loan is not
eligible]{.underline}. Attach additional sheet with Names and Legal
Forms if more than one OC. References below to OC mean
[each]{.underline} OC.*

Name of Operating Company
(OC)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Legal Form of Entity of
OC\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

-   The EPC will use the loan proceeds to acquire or lease, and /or
    improve or renovate real or personal

> property (including eligible refinancing) that it leases 100% to one
> or more OCs. YES\_\_\_NO\_\_\_

-   The OC is an eligible small business and the proposed use of
    proceeds would be an eligible use if

> the OC were obtaining the financing directly. YES\_\_\_NO\_\_\_

-   The EPC (with the exception of a trust) and the OC each are small
    under SBA's size standards. YES\_\_\_NO\_\_\_

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-   The EPC is eligible as to type of business, other than being
    passive. YES\_\_\_NO\_\_\_

-   The lease between the Eligible Passive Company and the Operating
    Company will be in writing,

> will have a remaining term at least equal to the term of the loan
> (including options to renew exercisable
>
> solely by the Operating Company), will be subordinated to SBA's lien
> on the property and the rents
>
> will be assigned as collateral for the loan. YES\_\_\_NO\_\_\_

-   The OC will be a guarantor or co-borrower. If loan proceeds include
    working capital or assets

> to be owned by the OC, it will be a co-borrower. YES\_\_\_NO\_\_\_

-   Each 20% or more owner of the EPC and each 20% or more owner of the
    OC will guarantee

> the loan. YES\_\_\_NO\_\_\_

-   The aggregate amount of the SBA portions for this application and
    for all outstanding loans to

> the EPC, the OC, and their affiliates does not exceed \$1.5 million.
> YES\_\_\_NO\_\_\_

-   Neither the EPC nor the OC is a trust or SBA requirements regarding
    trusts are met. YES\_\_\_NO\_\_\_

# 

# 

# 

# Use of Proceeds

\_\_\_To provide or refinance funds used for payments, distributions, or
loans to Associates of the Applicant.

*[If checked, loan is not eligible.]{.underline}*

\_\_\_For a purpose that will not benefit the small business. *[If
checked, loan is not eligible]{.underline}.*

\_\_\_To provide funds for floor plan financing. *[If checked, loan is
not eligible]{.underline}*

\_\_\_For debt refinancing. *If checked, ATTACH A DEBT SCHEDULE SHOWING
THE TERMS OF THE DEBT TO*

*BE REFINANCED AND THE JUSTIFICATION FOR THE REFINANCING. Also, answer
the following*

*questions. [If "No," loan is not eligible]{.underline}.*

-   Refinancing will provide a substantial benefit to Applicant of at
    least 20% needed improvement to

> cash flow or refinanced debt is short-term, involves a balloon
> payment, or is a long-term loan that is interest
>
> only. If more than one debt is refinanced, the new debt will have at
> least a 20% cashflow improvement over the combined cashflow of the
> debt being refinanced. YES\_\_\_NO\_\_\_

-   Existing debt no longer meets the needs of the Applicant.
    YES\_\_\_NO\_\_\_

-   If the loan to be refinanced is between the Applicant and the
    requesting SBA lender, in addition to the previous two bullets, it
    meets the following requirements:

> The loan to be refinanced was an [interim loan]{.underline} approved
> by the lender
>
> \(1\) within 90 days prior to the issuance of a PLP loan; AND
>
> \(2\) was for non-real estate construction purposes OR a construction
> loan that [has not been disbursed]{.underline}. YES\_\_\_NO\_\_\_

-   Proceeds will not pay a creditor in a position to sustain a loss
    causing a shift to SBA of all or

> part of a potential loss from an existing debt. YES\_\_\_NO\_\_\_

-   Debt to be refinanced is not a same institution SBA-guaranteed loan.
    YES\_\_\_NO\_\_\_

-   Loan will not refund debt to an SBIC. YES\_\_\_NO\_\_\_

-   Loan will not repay third party financing for any existing 504
    project. YES\_\_\_NO\_\_\_

-   Loan will not repay delinquent IRS withholding taxes, sales taxes or
    similar funds held in trust. YES\_\_\_NO\_\_\_

\_\_\_To fund or refinance a change in ownership. *[If checked, answer
the following questions. If "No," loan is not eligible.]{.underline}*

-   The change will promote the sound development or preserve the
    existence of the Applicant business. YES\_\_\_NO\_\_\_

>  If the business ownership has been transferred within 36 months
> prior to the date of the loan application AND the loan amount is over
> \$250,000, there are two appraisals of any commercial real estate
> securing the loan. The second appraisal may be a "review" of the first
> appraisal by another appraiser selected directly by the lender or if
> the first appraisal was requested by the lender, a site visit by a
> senior member of the lender's staff. YES\_\_\_NO\_\_\_

-   Change is 100% of ownership or a business repurchasing 100% of one
    or more of its owners'

> interests. YES\_\_\_NO\_\_\_

-   The loan proceeds will not pay off an SBA-guaranteed loan of the
    seller. YES\_\_\_NO\_\_\_

> [CHOOSE ONE:]{.underline}
>
> \_\_\_\_The 7(a) loan to finance the change of ownership is \$350,000
> or less AND there is no close relationship between the buyer and
> seller. The valuation of the business is supported by at least a
> lender's valuation. If the valuation analysis is performed by the
> lender's loan officer, [a synopsis is attached]{.underline}.
>
> \_\_\_\_The 7(a) loan to finance the change of ownership is more than
> \$350,000 OR there is a close relationship between the buyer and the
> seller. The lender has obtained an independent business valuation from
> a qualified source.

\_\_\_For construction of (or the refinancing of the construction for) a
new building.

*[If checked, answer the following questions. If "No" loan is not
eligible.]{.underline}*

-   If building will contain rental space, Applicant (or Operating
    Companies) will continue to occupy

> at least 60% of the rentable property for the term of the loan; lease
> long term no more than 20% of the
>
> rentable property to one or more tenants; plans to occupy within three
> years some of the remaining
>
> rentable property not immediately occupied or leased long term; and
> plans to occupy within ten years
>
> all of the rentable property not leased long term. YES\_\_\_NO\_\_\_

-   Community improvements do not exceed 5 percent of the loan amount.
    YES\_\_\_NO\_\_\_

-   If refinancing a construction loan, the construction loan is not
    with the same lender. YES\_\_\_NO\_\_\_

\_\_\_To provide funds for the acquisition of land or existing building
or for renovation or reconstruction of an existing building.

*[If checked, answer the following questions. If "No" loan is not
eligible.]{.underline}*

-   Applicant (or Operating Companies) will occupy at least 51% of the
    rentable property. YES\_\_\_NO\_\_\_

-   Loan proceeds will not be used to remodel or convert any rental
    space in the property. YES\_\_\_NO\_\_\_

\_\_To provide funds for or refinance leasehold improvements. *If
checked, answer the following question.*

*[If "No" loan is not eligible.]{.underline}*

Loan proceeds will be used to improve space occupied 100% by Applicant.
YES\_\_\_NO\_\_\_

\_\_\_To provide funds to guarantee or fund a letter of credit. *[If
checked, loan is not eligible for PLP.]{.underline}*

**[Special Program Requirements]{.underline}**

\_\_\_Loan is one of the following special purpose loans *([Loan is not
eligible for PLP]{.underline}):*

-   Disabled Assistance Loan Program (DAL)

-   Energy Loans as described in §7(a)(12) of the Small Business Act
    (Note: this does not include

> Loans where the borrower is purchasing, installing or otherwise
> utilizing equipment designed
>
> for its own energy conservation.)

-   Qualified Employee Trusts (ESOP)

-   Pollution Control program

-   CAPLines Program (including Builders Loan Program)

-   Community Adjustment and Investment Program (CAIP)

\_\_\_Loan is a revolving credit. *[If checked, answer the following
question]{.underline}*.

> Loan is being made under the Export Working Capital Program (EWCP) and
> the requesting lender has special authority from SBA to make PLP EWCP
> loans. (*[If no, loan is not eligible.]{.underline}*)
> YES\_\_\_NO\_\_\_

\_\_\_ Loan is under International Trade Program (IT). *Answer the
following questions. [If "No," loan is not eligible]{.underline}.*

-   The loan proceeds will be used solely for the purpose of 1)
    financing the acquisition, construction,

> renovation, modernization, improvement, or expansion of productive
> facilities or equipment to be used in the
>
> United States in the production of goods and services involved in
> international trade; or 2) the refinancing of
>
> existing indebtedness that was used for these same purposes that is
> not structured with reasonable terms and
>
> conditions. There can be no working capital provided by the loan
> proceeds. YES\_\_\_NO\_\_\_

-   The small business concern is either 1) in a position to expand
    existing export markets or develop new

> export markets or 2) is confronting increased competition with foreign
> firms in the relevant market and is
>
> injured by such competition. YES\_\_\_NO\_\_\_

-   Lender will take a first lien on the fixed assets financed (or
    re-financed) with this loan. YES\_\_\_NO\_\_\_

-   Collateral is located in the United States, its territories and
    possessions YES\_\_\_NO\_\_\_

-   Lender has reviewed the Ex-Im Bank Country Limitation Schedule (CLS)
    to verify that the U.S. Government has not restricted trade with any
    foreign country that the applicant does business with (i.e., no
    country is identified on the CLS by Note #7). YES\_\_\_NO\_\_\_

\_\_\_ Lender has made a personal loan to an individual for the purpose
of providing an equity injection into the business.

(*[Loan is not eligible for PLP]{.underline}.)* YES\_\_\_NO\_\_\_

\_\_\_Applicant or Affiliates(s) has/have existing SBA loan(s)*. If
checked, answer the following question. [If "No" loan is not
eligible.]{.underline}*

The existing SBA loan(s) is/are current. YES\_\_\_NO\_\_\_

\_\_\_Question 7 on any required SBA Form 912, Statement of Personal
History, for this application is

answered "Yes." *([Loan is not eligible]{.underline}.)*

\_\_\_Question 8 or 9 on any required SBA Form 912, Statement of
Personal History, for this application is

answered "Yes." If checked, answer the following:

The application meets one of the following criteria below (which is
checked): YES\_\_\_NO\_\_\_

(If "no," loan is not eligible for PLP.)

\_\_\_\_\_Lender has received written clearance of the character
issue(s) from the district or branch SBA office

serving the territory where the business applicant is located.

\_\_\_\_\_The charge resulting in a "yes" answer was a single
misdemeanor that was subsequently dropped without

> prosecution and Lender has documentation from the appropriate court or
> prosecutor's office showing that the charge was dropped.

\_\_\_ Lender is aware that the application was previously submitted to
SBA under any SBA program, including SBA Express,

Community Express, PLP, CLP, Patriot Express or regular 7(a). (*[Loan is
not eligible for PLP]{.underline}.)*

\_\_\_Loan will be collateralized by commercial property that will not
meet SBA's environmental requirements or that will require

use of a non-standard indemnification agreement. *([Loan is not eligible
for PLP]{.underline}.)*

\_\_\_Business or any of its principals has been involved in a federal
loan or federally assisted financing that defaulted

and caused a loss to the Federal government or any of its Departments or
agencies. *[(Loan is not eligible for PLP]{.underline}.)*

# Conflict of Interest

# *SBA many not provide financial assistance to an applicant where there is any appearance of a conflict of interest on the part of SBA or the Lender. All statements must be answered as "True" to be eligible.*

-   No SBA employee, the employee's close relative or a member of the
    employee's household is an employee, officer, director, attorney,
    agent, creditor or debtor, or has a financial interest in the
    Applicant. True\_\_\_\_

-   No former SBA employee separated from SBA for less than one year is
    an employee, officer, director, attorney, agent, creditor or debtor,
    or has a financial interest in the Applicant. True\_\_\_\_

-   No individual currently involved in a Small Business Development
    Center program, the individual's close relative or a member of the
    individual's household is an employee, officer, director, attorney,
    agent, creditor or debtor, or has a financial interest in the
    Applicant. True\_\_\_\_

-   No member of Congress or an appointed official or employee of the
    legislative or judicial branch (or a close relative or household
    member of such an individual) is a sole proprietor, general partner,
    officer, director, employee, attorney, agent, creditor or debtor, or
    has a financial interest in the Applicant. True\_\_\_\_

-   If an Associate\*\* of the small business or member of any
    Associate's household is a GS-13 or higher government employee or a
    Major or Lieutenant Commander or higher in the military, the small
    business applicant has submitted to the Lender a statement of no
    objection by the pertinent government department or military
    service. True\_\_\_\_

-   No member or employee of a Small Business Advisory Council or a
    SCORE volunteer (or a close relative or household member of such an
    individual) is a sole proprietor, general partner, officer,
    director, employee, attorney, agent, creditor or debtor, or has a
    financial interest in the Applicant. True\_\_\_\_

-   No employee of a community organization such as a certified
    development company or microlender (or a close relative or household
    member of such an individual) is a sole proprietor, general partner,
    officer, director, employee, attorney, agent, creditor or debtor, or
    has a financial interest in the Applicant. True\_\_\_\_

-   No community organization or its officers or its directors have a
    significant financial interest in the Applicant unless the
    organization has been inactive in packaging SBA loans for at least
    two years prior to the application date. True\_\_\_\_

-   No Lender or Associate\*\* of Lender has a real or apparent conflict
    of interest with Applicant, any of Applicant's Associates, or any of
    the close relatives of Applicant's Associates. True\_\_\_\_

-   No Lender or Associate or close relative of an associate of the
    lender has a significant direct or indirect financial or other
    interest in the applicant, or has had such an interest within 6
    months prior to the date of the application. True\_\_\_\_

-   No Associate of a Lender is incarcerated, on parole, or on probation
    or is a convicted felon or has an adverse final civil judgment (in a
    case involving fraud, breach of trust, or other conduct) that would
    cause the public to question the Lender's business integrity.
    True\_\_\_\_

-   No Lender or any Associate of Lender has accepted funding from a
    source that restricts, prioritizes, or conditions the types of small
    businesses that Lender may assist under an SBA program or that
    imposes any conditions or requirements upon recipients of SBA
    assistance inconsistent with SBA's loan programs or regulations.
    True\_\_\_\_

-   None of the Loan proceeds will directly or indirectly finance
    purchase of real estate, personal property or services from Lender
    or an Associate of Lender. True\_\_\_\_

-   Neither the Applicant, an Associate of Applicant, close relative nor
    household member of an Associate of Applicant is required to invest
    in Lender. True\_\_\_\_

-   None of the proceeds of the loan will be used to acquire space in
    project for which lender has issued a real estate forward
    commitment. True\_\_\_\_

(\*\*Associate of a Lender is an officer, director, key employee, or
holder of 20 percent or more of the value of the Lender's stock or debt
instruments. An Associate of a small business is an officer, director,
owner of more than 20 percent of the equity, or key employee.)

Lender hereby certifies that the above information is true and correct,
to the best of its knowledge, and that it has exercised due diligence to
obtain the true and correct information. Lender is aware and
acknowledges that SBA review of this form is a quick look at eligibility
intended to provide limited protection to SBA and the lender from making
an ineligible loan on which SBA could not honor its guarantee and that
if an SBA loan number is assigned and SBA later learns that the loan is
not eligible, SBA still may deny liability on its guarantee.

**Lender Signature:
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Date\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Typed Name and Title:
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