Paycheck Protection Program 

Lender Application Form - Paycheck Protection Program Loan Guaranty 

SBA Form 2484 (Revised 04/20) 1 

OMB Control No.: 3245-0407 

Expiration Date: 09/30/2020

The purpose of this form is to collect identifying information about the Lender, the Applicant, the loan guaranty request, sources and uses of funds, the 

proposed structure (which includes pricing and the loan term), and compliance with SBA Loan Program Requirements. This form reflects the data fields 

that will be collected electronically from lenders; no paper version of this form is required or permitted to be submitted. As used in this application, 

“Paycheck Protection Program Rule” refers to the rules in effect at the time you submit this application that have been issued by the Small Business 

Administration (SBA) implementing the Paycheck Protection Program under Division A, Title I of the Coronavirus Aid, Relief, and Economic Security 

Act (CARES Act). 

Instructions for Lenders 

All Paycheck Protection Program (PPP) loans are processed by all Lenders under delegated authority from SBA. This application must be submitted and 

signed electronically in accordance with program requirements, and the information requested is to be retained in the Lender’s loan file. 

A. Lender Information 

Lender Name: Lender Location ID: 

Address: City: St: Zip: 

Lender Contact: Ph: ( ) - Cell or Ext: ( ) - 

Contact Email: Title: 

B. Applicant Information Applicant 

Check One:  Sole Proprietor  Partnership  C-Corp  S-Corp  LLC  Independent contractor 

  Eligible self-employed individual  501(c)(3) nonprofit  501(c)(19) veterans organization 

  Tribal business (sec. 31(b)(2)(C) of Small Business Act)  Other 

Applicant Legal Name: ____________________________ 

DBA: ____________________________ Business Tax ID: ___________________ 

Applicant Address: ____________________________ City, State, Zip: 

____________________________ 

Applicant Primary Contact: Phone: ( ) - 

C. Loan Structure Information 

Amount of Loan Request: $ Guarantee %: 100% Loan Term in # of Months: 24 Payment: Deferred 6 mos. 

Applicant must provide documentation to Lender supporting how the loan amount was calculated in accordance with the Paycheck Protection 

Program Rule and the CARES Act, and Lender must retain all such supporting documentation in Lender’s file. 

Interest Rate: 1% 

D. Loan Amount Information 

Average Monthly Payroll multiplied by 2.5 $ 

Refinance of Eligible Economic Injury Disaster Loan, net of Advance (if Applicable; see Paycheck 

Protection Program Rule) 

$ 

Total $ 

E. General Eligibility (If the answer is no to either, the loan cannot be approved)

 The Applicant has certified to the Lender that (1) it was in operation on February 15, 2020 and had employees for 

whom the Applicant paid salaries and payroll taxes or paid independent contractors, as reported on Form(s) 1099-

MISC, (2) current economic uncertainty makes this loan request necessary to support the ongoing operations of the 

Applicant, (3) the funds will be used to retain workers and maintain payroll or make mortgage interest payments, 

lease payments, and utility payments, and (4) the Applicant has not received another Paycheck Protection Program 

loan. 

 Yes  No 

 The Applicant has certified to the Lender that it (1) is an independent contractor, eligible self-employed individual, 

or sole proprietor or (2) employs no more than the greater of 500 or employees or, if applicable, meets the size 

standard in number of employees established by the SBA in 13 C.F.R. 121.201 for the Applicant’s industry.

 Yes  No 

F. Applicant Certification of Eligibility (If not true, the loan cannot be approved)

 The Applicant has certified to the Lender that the Applicant is eligible under the Paycheck Protection Program Rule.  True

G. Franchise/License/Jobber/Membership or Similar Agreement (If applicable and no, the loan cannot be approved)

 The Applicant has represented to the Lender that it is a franchise that is listed in the SBA’s Franchise Directory.  Yes  No 
SBA Form 2484 (Revised 04/20) 2 

H. Character Determination (If no, the loan cannot be approved)

 The Applicant has represented to the Lender that neither the Applicant (if an individual) nor any individual owning 

20% or more of the equity of the Applicant is subject to an indictment, criminal information, arraignment, or other 

means by which formal criminal charges are brought in any jurisdiction, or is presently incarcerated, or on probation 

or parole. 

 Yes  No 

 The Applicant has represented to the Lender that neither the Applicant (if an individual) nor any individual owning 

20% or more of the equity of the Applicant has within the last 5 years, for any felony: 1) been convicted; 2) pleaded 

guilty; 3) pleaded nolo contendere; 4) been placed on pretrial diversion; or 5) been placed on any form of parole or 

probation (including probation before judgment). 

 Yes  No 

I. Prior Loss to Government/Delinquent Federal Debt (If no, the loan cannot be approved)

 The Applicant has certified to the Lender that neither the Applicant nor any owner (as defined in the Applicant’s 

SBA Form 2483) is presently suspended, debarred, proposed for debarment, declared ineligible, voluntarily 

excluded from participation in this transaction by any Federal department or agency, or presently involved in any 

bankruptcy. 

 Yes  No 

 The Applicant has certified to the Lender that neither the Applicant nor any of its owners, nor any business 

owned or controlled by any of them, ever obtained a direct or guaranteed loan from SBA or any other Federal 

agency that is currently delinquent or has defaulted in the last 7 years and caused a loss to the government. 

 Yes  No 

J. U.S. Employees (If no, the loan cannot be approved)

 The Applicant has certified that the principal place of residence for all employees included in the Applicant’s 

payroll calculation is the United States.  Yes  No 

K. Fees (If yes, Lender may not pass any agent fee through to the Applicant or offset or pay the fee with the proceeds of this loan)

 Is the Lender using a third party to assist in the preparation of the loan application or application materials, or to 

perform other services in connection with this loan?  Yes  No

SBA Certification to Financial Institution under Right to Financial Privacy Act (12 U.S.C. 3401) 

By signing SBA Form 2483, Borrower Information Form in connection with this application for an SBA-guaranteed loan, the Applicant certifies that it 

has read the Statements Required by Law and Executive Orders, which is attached to Form 2483. As such, SBA certifies that it has complied with the 

applicable provisions of the Right to Financial Privacy Act of 1978 (12 U.S.C. 3401) and, pursuant to that Act, no further certification is required for 

subsequent access by SBA to financial records of the Applicant/Borrower during the term of the loan guaranty. 

Lender Certification 

On behalf of the Lender, I certify that: 

 The Lender has complied with the applicable lender obligations set forth in paragraphs 3.b(i)-(iii) of the Paycheck Protection Program Rule. 

 The Lender has obtained and reviewed the required application (including documents demonstrating qualifying payroll amounts) of the Applicant 

and will retain copies of such documents in the Applicant’s loan file. 

I certify that: 

 Neither the undersigned Authorized Lender Official, nor such individual’s spouse or children, has a financial interest in the Applicant. 

Authorized Lender Official: Date: 

 Signature 

 

Type or Print Name: Title: 

NOTE: According to the Paperwork Reduction Act, you are not required to respond to this collection of information unless it displays a currently 

valid OMB Control Number. The estimated burden for completing this form, including time for reviewing instructions, gathering data needed, and 

completing and reviewing the form is 25 minutes per response. Comments or questions on the burden estimates should be sent to U.S. Small 

Business Administration, Director, Records Management Division, 409 3rd St., SW, Washington DC 20416, and/or SBA Desk Officer, Office of 

Management and Budget, New Executive Office Building, Rm. 10202, Washington DC 20503. PLEASE DO NOT SEND FORMS TO THESE 

ADDRESSES.