Paycheck Protection Program

Lender’s Application - Paycheck Protection Program Loan Guaranty

Revised January 8, 2021

SBA Form 2484 (Revised 1/21) 1

OMB Control No.: 3245-0407 

Expiration Date: 7/31/2021

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 Rules” refers to the rules in effect at the time you submit this application that have been issued by the Small 

Business Administration (SBA) and the Department of the Treasury implementing the Paycheck Protection Program under Division A, Title I of the 

Coronavirus Aid, Relief, and Economic Security Act (CARES Act) and the Economic Aid to Hard-Hit Small Businesses, Nonprofits, and Venues 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: 

Contact Email: _______________________________________________ 

Cell or Ext: 

Title: _______________________________________________

B. Applicant Information (All Applicant Ownership information provided by the Applicant on SBA Form 2483 must also be submitted electronically) Applicant

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

Self-employed individual 501(c)(3) nonprofit 501(c)(6) organization

501(c)(19) veterans organization Housing cooperative Tribal business Other

Applicant Legal Name: NAICS Code: 

DBA or Tradename (if applicable): Business Tax ID:

Year of Establishment (if applicable): Number of Employees:

Applicant Size Standard (including 

affiliates, if applicable) (check one): 

 No more than 500 employees (or 300 employees, if applicable)

 SBA industry size standards

 SBA alternative size standard

Applicant Street Address (no P.O. 

Box Addresses allowed): City, State, Zip:

Applicant Primary Contact: Phone: 

C. Loan Structure Information

Amount of Loan Request: $ Guarantee %: 100% Loan Term in # of Months: 60 Payment: Deferred 

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

Program Rules and Lender must retain all such supporting documentation in Lender’s file.

Interest Rate: 1% (calculated on a non-compounding, non-adjustable basis)

D. Loan Amount Information

Average Monthly Payroll multiplied by 2.5 $ 

Refinance of Eligible Economic Injury Disaster Loan (EIDL) (Do Not Include Any EIDL Advance (see Paycheck Protection 

Program Rules)) $ 

Total $ 
SBA Form 2484 (Revised 1/21) 2 

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

• The Applicant has certified to the Lender that (1) it was in operation on February 15, 2020, has not permanently closed,

and was either an eligible self-employed individual, independent contractor, or sole proprietorship with no employees or 

had employees for whom it 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 payments for mortgage interest, rent, 

utilities, covered operations expenditures, covered property damage costs, covered supplier costs, and covered worker 

protection expenditures; and (4) the Applicant has not and will not receive another loan under the Paycheck Protection 

Program, section 7(a)(36) of the Small Business Act (15 U.S.C. 636(a)(36)) (this does not include Paycheck Protection 

Program second draw loans, section 7(a)(37) of the Small Business Act (15 U.S.C. 636(a)(37)).

 Yes  No

• The Applicant has certified to the Lender that the Applicant, together with its affiliates (if applicable), (1) is an 

independent contractor, self-employed individual, or sole proprietor with no employees; (2) if not a housing cooperative, 

eligible 501(c)(6) organization, or eligible destination marketing organization, employs no more than the greater of 500 

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; (3) if a housing cooperative, eligible 501(c)(6) organization, or eligible destination marketing 

organization, employs no more than 300 employees; (4) if NAICS 72, employs no more than 500 employees per physical 

location; (5) if a news organization that is majority owned or controlled by a NAICS code 511110 or 5151 business or a 

nonprofit public broadcasting entity with a trade or business under NAICS code 511110 or 5151, employs no more than 

500 employees (or, if applicable, the size standard in number of employees established by SBA in 13 C.F.R. 121.201 for 

the Applicant’s industry) per location; or (6) is a small business under the applicable revenue-based size standard 

established by SBA in 13 C.F.R. 121.201 for the Applicant’s industry or under the SBA alternative size standard.

 Yes  No

• The Applicant has certified to the Lender that (1) it has not and will not receive a Shuttered Venue Operator grant from 

SBA; (2) the President, the Vice President, the head of an Executive department, or a Member of Congress, or the spouse 

of such person as determined under applicable common law, does not directly or indirectly hold a controlling interest in the 

Applicant, with such terms having the meanings provided in Section 322 of the Economic Aid to Hard-Hit Small 

Businesses, Nonprofits, and Venues Act; and (3) the Applicant is not an issuer, the securities of which are listed on an 

exchange registered as a national securities exchange under section 6 of the Securities Exchange Act of 1934 (15 U.S.C. 

78f).

 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 Rules.  True

G. Franchise/License/Jobber/Membership or Similar Agreement (If a franchise and not listed in the SBA Franchise Directory, the loan 

cannot be approved)

• The Applicant has represented to the Lender that it is a franchise.

• The Applicant has represented that the franchise is listed in SBA’s Franchise Directory.

• If Yes, enter the SBA Franchise Identifier Code here: _______________

  Yes  No

  Yes  No

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 presently incarcerated or, for any felony, presently subject to an indictment, criminal 

information, arraignment, or other means by which formal criminal charges are brought in any jurisdiction. 

 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 involving fraud, bribery, embezzlement, or a 

false statement in a loan application or an application for federal financial assistance, or within the last year for any other 

felony: 1) been convicted; 2) pleaded guilty; 3) pleaded nolo contendere; or 4) commenced 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 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 (a) 

currently delinquent, or (b) 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)

• Has the Lender directly contracted with 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 Form 2484 (Revised 1/21) 3 

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

By signing SBA Form 2483, Borrower Application 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 C.3.a.-c. of the interim final rule “Paycheck Protection 

Program as Amended by Economic Aid Act” (issued on January 6, 2021), and any amendments thereto. 

• 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. 

• The Lender will register in sam.gov no later than thirty (30) days from the date of the first disbursement of a PPP loan made by the Lender after 

January 7, 2021 and will provide SBA with the Lender’s unique entity identifier.

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.