SSBCI TA Grant Program Reporting Guidance 

DRAFT as of June 7, 2023 

1

U.S. Department of the Treasury

State Small Business Credit Initiative

Technical Assistance Grant Program Reporting Guidance

DRAFT AS OF JUNE 7, 2023 

Table of Contents

Section I. Overview ....................................................................................................................... 2

Section II. Definitions ................................................................................................................... 3

Section III. Reporting Deadlines ................................................................................................. 5

a. Semiannual and Annual Reports During the Period of Performance ........................................ 5

1. Semiannual Federal Financial Report.......................................................................................... 5

2. Annual TA Project Progress and Outcomes Report ..................................................................... 6

b. Final Report at the Expiration of the Period of Performance .................................................... 6

c. Summary of Reporting Deadlines ................................................................................................. 7

Section IV. Interim Reporting on Significant Developments; Notification of Fraud, Waste, 

or Abuse ......................................................................................................................................... 7

Section V. Annual and Final Reports .......................................................................................... 8

a. Annual TA Project Progress and Outcomes Reports .................................................................. 8

b. Final TA Project Progress and Outcomes Report ..................................................................... 26

Section VI. Reporting Subawards and Executive Compensation, Maintenance of and 

Access to Records, and Increase of Frequency and Scope of Reporting ............................... 27

Appendix 1 ................................................................................................................................... 29

Appendix 2 ................................................................................................................................... 31

Appendix 3 ................................................................................................................................... 34

Appendix 4 ................................................................................................................................... 35

Paperwork Reduction Act 

The information collections discussed in this guidance will be submitted to the Office of 

Management and Budget (OMB) under OMB control number 1505-0227 in accordance with the 

Paperwork Reduction Act of 1995 (44 U.S.C. chapter 35). OMB approval for the information 

collections included in this guidance is forthcoming and the information must be collected following 

OMB approval. This document will be updated to reflect that approval.
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Section I. Overview

The American Rescue Plan Act of 2021 (ARPA) reauthorized and amended the Small Business 

Jobs Act of 2010 to provide $10 billion to fund the State Small Business Credit Initiative 

(SSBCI). SSBCI is a federal program administered by the U.S. Department of the Treasury 

(Treasury) that is intended to expand access to capital, promote economic resiliency, create new 

jobs, and increase economic opportunity. ARPA includes $500 million for technical assistance 

(TA) funding. Treasury intends to award $200 million in federal grants to eligible recipients for 

the provision of legal, accounting, and financial advisory services (TA services) to eligible small 

businesses (TA Grant Program). The SSBCI Technical Assistance Grant Program Guidelines 

were published on April 28, 2022.1

TA Grants will be used to fund eligible TA providers’ provision of TA services to eligible 

beneficiaries. Eligible beneficiaries are very small businesses (VSBs) and businesses owned and 

controlled by socially and economically disadvantaged individuals (SEDI-owned businesses) 

that are applying for, preparing to apply for, or have previously applied for an SSBCI capital 

program or other federal or other jurisdiction small business program. 

This guidance details the reporting and document-retention requirements for jurisdictions that 

received a TA Grant (TA Grant recipients). Treasury will provide an online reporting portal that

TA Grant Program recipients must use to submit reports regarding their TA Grants.2 Treasury 

will provide more information about the submission format for reports in the coming months. 

This guidance may be updated periodically. 

Section II sets forth definitions of terms used in this guidance. Section III specifies the deadlines 

for TA Grant recipients to submit reports. Section IV describes requirements relating to interim 

reporting. Section V provides details regarding the information TA Grant Recipients must report 

to Treasury in the required reports, which will support award implementation and compliance, as 

well as assessment of outcomes. Section VI specifies additional requirements for TA Grant 

recipients related to subaward and execution compensation reporting, maintenance of and access 

to records and the frequency of reporting. 

Treasury may release public reports or data based on the information reported by TA Grant 

recipients. In any public report or data, Treasury will, subject to applicable laws and regulations, 

withhold information that appears to be personally identifiable information (PII) and other 

sensitive information such as sensitive commercial or financial information associated with an 

individual person or business. 

Each TA Grant recipient is responsible for the implementation of its TA Grant approved by 

Treasury, in accordance with the terms and conditions of its SSBCI TA Grant Agreement, 

including applicable legal, regulatory, and program requirements. Each TA Grant recipient must 

1 The SSBCI Technical Assistance Grant Program Guidelines in effect as of the date of this guidance are available at 

https://home.treasury.gov/system/files/136/SSBCI-Technical-Assistance-Guidelines-April-2022.pdf. 2 To the extent that Treasury distributes templates or other materials to help carry out this TA Grant Reporting 

Guidance, TA Grant recipients should follow the instructions included in those reporting materials.
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submit a certification using the form in Appendix 3 with every required report. In the case of a 

non-Tribal entity or Tribal-affiliated entity (referred to as “Agent for the Tribes”) that directly 

applies for and administers a TA Grant on behalf of a group of Tribal governments, the Agent for 

the Tribes (in its individual capacity) must, in addition to the Appendix 3 certification, submit a 

certification using the form in Appendix 4 prior to application approval and upon submission of 

each required TA Grant Program report or request for additional disbursements of funding. 

Section II. Definitions

The following definitions apply in this guidance.

Classroom-style TA. TA services that are provided through a stand-alone event that is targeted 

towards eligible beneficiaries and has more than 10 attendees. 

Eligible beneficiary. Any VSB or SEDI-owned businesses that is applying for, preparing to 

apply for, or has previously applied for an SSBCI capital program or other federal or jurisdiction 

small business program. 

Eligible recipient. States, the District of Columbia, territories and Tribal governments that 

submitted a timely and complete SSBCI capital program application. 

Legal, accounting, or financial advisory firm. A nonprofit or for-profit entity that meets at least 

one of the following criteria: 

a. A primary purpose of the entity or a central part of the entity’s mission is to provide 

legal, accounting, and/or financial advisory services, 

b. The entity regularly markets or publicizes itself as providing legal, accounting, and/or 

financial advisory services, or 

c. At least 25% of the entity’s revenues or staff are dedicated to providing legal, accounting, 

and/or financial advisory services.

Legal, accounting, and/or financial advisory services. The services listed in Section IV of the 

SSBCI TA Grant Program Guidelines and other services that are similar to the those listed.

Minority individual. A natural person who identifies as American Indian or Alaska Native; 

Asian American; Black or African American; Native Hawaiian or Other Pacific Islander; 

Hispanic or Latino/a; or one or more than one of these groups. 

Minority-owned or controlled business. A business that: 

(1) if privately owned, 51 percent or more is owned by minority individuals; 

(2) if publicly owned, 51 percent or more of the stock is owned by minority individuals; 

(3) in the case of a mutual institution, a majority of the board of directors, account holders, and 

the community which the institution services is predominantly comprised of minority 

individuals; or 

(4) one or more minority individuals have the power to exercise a controlling influence over the 

business. 
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Principal owner. A natural person who directly or indirectly, through any contract, arrangement, 

understanding, relationship or otherwise, owns 25 percent or more of the equity of the business. 

If a trust owns, directly or indirectly, through any contract, arrangement, understanding, 

relationship or otherwise, 25 percent or more of the equity interests of the business, the trustee is 

a principal owner.

SEDI-owned business.

• a business enterprise that certifies that it is owned and controlled by individuals who have 

had their access to credit on reasonable terms diminished compared to others in 

comparable economic circumstances, due to (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) disability, (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 an underserved 

community (see Executive Order 13985, under which “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.); 

• a business enterprise that certifies that it is owned and controlled by individuals whose 

residences are in Community Development Financial Institution (CDFI) Investment 

Areas, as defined in 12 C.F.R. § 1805.201(b)(3)(ii);3

• a business enterprise that certifies that it will build, open, or operate a location in a 

CDFI Investment Area, as defined in 12 C.F.R. § 1805.201(b)(3)(ii); or

• a business enterprise that certifies that it is located in a CDFI Investment Area, as defined 

in 12 C.F.R. § 1805.201(b)(3)(ii). 

For purposes of the definition of “SEDI-owned business,” a business is “owned and 

controlled” by applicable individuals: 

(1) if privately owned, 51 percent or more is owned by such individuals;

(2) if publicly owned, 51 percent more or of the stock is owned by such individuals; and

3 The CDFI Fund evaluates Puerto Rico, but not other territories, in identifying CDFI Investment Areas. For 

purposes of the SSBCI, Treasury has also evaluated American Samoa, Guam, the Northern Mariana Islands, and the 

U.S. Virgin Islands and has determined that these territories in their entirety constitute CDFI Investment Areas, 

because each of these territories has a poverty rate of at least 20 percent. See 12 C.F.R. § 1805.201(b)(3)(ii)(D)(1).
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(3) in the case of a mutual institution, if a majority of the board of directors, account holders, 

and the community which the institution services is predominantly comprised of such 

individuals. 

Very small business (VSB). A business with fewer than 10 employees and includes independent 

contractors and sole proprietors. 

Veteran-owned or controlled business. A business that: 

(1) if privately owned, 51 percent or more is owned by veterans; 

(2) if publicly owned, 51 percent or more of the stock is owned by veterans; 

(3) in the case of a mutual institution, a majority of the board of directors, account holders, and 

the community which the institution services is predominantly comprised of veterans; or 

(4) one or more individuals who are veterans have the power to exercise a controlling influence 

over the business. 

Women-owned or controlled business. A business that: 

(1) if privately owned, 51 percent or more is owned by females; 

(2) if publicly owned, 51 percent or more of the stock is owned by females; 

(3) in the case of a mutual institution, a majority of the board of directors, account holders, and 

the community which the institution services is predominantly comprised of females; or 

(4) one or more individuals who are females have the power to exercise a controlling influence 

over the business. 

Section III. Reporting Deadlines

a. Semiannual and Annual Reports During the Period of Performance

1. Semiannual Federal Financial Report

During the period of performance set forth in the SSBCI TA Grant Agreement that each 

TA Grant recipient executed in connection with their TA Grant, the TA Grant recipient must 

submit a Form SF-425 (Federal Financial Report) to Treasury with cumulative information on a 

semiannual basis with the first report period starting on the Federal Award Date and ending on 

the sooner of the following March 31 or September 30.4

 Thereafter, the semiannual reports must 

cover six month periods ending on March 31 and September 30 of each year until the period of 

performance ends on the TA Grant in accordance with 2 C.F.R. § 200.328.5 The Form SF-425 is 

4 For TA Grants awarded fewer than 30 calendar days prior to the end of the semiannual reporting period (March 31 

or September 30, as appropriate), the recipient will not be required to submit a semiannual report for that period. 

However, information for that first semiannual reporting period should be included in the next period’s semiannual 

report.

5 In accordance with 2 C.F.R. 200.328, when a TA Grant Program recipient has submitted a Form SF-425 for 

purposes of facilitating a disbursement under a TA Grant within three months prior to an applicable semiannual 

report submission deadline, Treasury will consider that Form SF-425 to satisfy the semiannual reporting submission 

and no further reports for that period need be submitted. For example, if a TA Grant recipient submits a 

Form SF-425 in support of a disbursement request on March 1, 2024, Treasury will consider the Form SF-425 to 

satisfy the recipient’s required report submission for the semiannual period ending March 31, 2024. 
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due at the end of the calendar month following the end of the reporting period (April 30 and 

October 31).6

 

In addition, for TA Grants that are $250,000 or less, the TA Grant Program recipient must 

provide Treasury at the time of submission of the Form SF-425 with cumulative information for 

the entire period of performance to date as of March 31 and September 30 of each year on 

amounts expended to administer and oversee the award (administrative costs). As applicable to a 

given award, such amounts may include direct administrative costs such as personnel, fringe, and 

contractual costs, or indirect costs.7

 To satisfy this requirement, these recipients are only required 

to report a single dollar amount of cumulative administrative costs.

Form SF-425 is available on Grants.gov along with instructions for completing the form at: 

https://www.grants.gov/forms/post-award-reporting-forms.html. Table 1 below summarizes all 

reporting deadlines. 

2. Annual TA Project Progress and Outcomes Report 

During the period of performance as set forth in the SSBCI TA Grant Agreement, each TA Grant 

recipient must submit an Annual TA Project Progress and Outcomes Report for the 12-month 

period ending March 31 (or any portion thereof, as applicable) of each year until the period of 

performance ends on the TA Grant in accordance with 2 C.F.R. § 200.329. The first Annual TA 

Project Progress and Outcomes Report period will start on the Federal Award Date and end on 

March 31.

8

 The Annual TA Project Progress and Outcomes Report is due at the end of the 

calendar month following the end of the reporting period (April 30).9 Table 1 below summarizes 

all reporting deadlines. The data elements in the Annual TA Project Progress and Outcomes 

report are set out in Section IV below. 

b. Final Report at the Expiration of the Period of Performance 

In accordance with 2 C.F.R. § 200.344(a), each TA Grant Program recipient must submit a 

Final TA Project Progress and Outcomes Report and a final Form SF-425 no later than 

120 calendar days after the end date of the period of performance as set forth in the SSBCI 

TA Grant Agreement. 

In accordance with 2 C.F.R. § 200.344(a), any subrecipient must submit to the TA Grant 

recipient, no later than 90 calendar days after the period of performance end date (or an earlier 

date as agreed upon by the recipient and subrecipient), all financial, performance, and other 

reports, as required by the terms and conditions of the subaward agreement (see Section III.C of 

6 If this deadline falls on a federal holiday or a weekend, the deadline will be the following business day.

7 For TA Grants that are $250,000 or less, fixed amount award procedures apply and therefore recipients are not 

required to submit a budget or narrative justification. To help monitor the use of TA Grant funds, obtaining 

information on the amount of funding used to administer and oversee awards is critical. 8 For TA Grants awarded fewer than 30 calendar days prior to the end of the annual reporting period (March 31), the 

recipient will not be required to submit an annual report for that period. However, information for that first annual 

reporting period should be included in the next period’s annual report.

9 If this deadline falls on a federal holiday or a weekend, the deadline will be the following business day.
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the SSBCI TA Grant Program Guidelines for more information on requirements for subaward 

agreements). 

c. Summary of Reporting Deadlines 

Table 1. Summary of TA Grant Program Reporting Deadlines 

Phase Reports Submission Deadlines

During the Period 

of Performance

Form SF-425 

For TA Grants $250,000 or 

less, cumulative information 

on administrative costs. 

Semiannually on April 30 (cumulative 

information through March 31) and 

October 31 (cumulative information through 

September 30).

Annual TA Project Progress 

and Outcomes Report

Annually, for the period ending March 31 

(due April 30).

At the Expiration 

of the Period of 

Performance but 

Before Award 

Closeout 

Final TA Project Progress 

and Outcomes Report and 

final Form SF-425 

One time report, due no later than 

120 calendar days after the end date of the 

award period of performance. 

A subrecipient must submit required final 

reports to the TA Grant recipient not later 

than 90 calendar days after the end date of 

the award period of performance (or an 

earlier date agreed upon by the recipient and 

subrecipient) (See Section II.b above). 

Section IV. Interim Reporting on Significant Developments; Notification of Fraud, Waste, 

or Abuse

In accordance with 2 C.F.R. § 200.329(e), events may occur between the scheduled performance 

reporting dates that have significant impact upon a TA Grant or activities conducted under the 

award. In such cases, the recipient must inform Treasury as soon as the following types of 

conditions become known: 

a. Problems, delays, or adverse conditions which will materially impair the ability to 

meet the objective of the award. This disclosure must include a statement of the 

action taken, or contemplated, and any assistance needed to resolve the situation. 

b. Favorable developments, which enable meeting time schedules and objectives sooner 

or at less cost than anticipated or producing more or different beneficial results than 

originally planned. 
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In addition, the recipient must immediately notify Treasury and the Treasury Inspector General 

of any indication of fraud, waste, abuse, or potentially criminal activity pertaining to the TA 

Grant Program funds.

Section V. Annual and Final Reports

Treasury intends to provide TA Grant recipients forms to assist with reporting all data elements. 

The semiannual, annual, and final reports submitted by TA Grant recipients for their TA Grant 

(or data contained therein) may be posted on Treasury’s website, used for policy reviews, or may 

be otherwise shared. In any public report or data, Treasury will, subject to applicable laws and 

regulations, withhold information that appears to be personally identifiable information (PII) and 

other sensitive information such as sensitive commercial or financial information associated with 

an individual person or business.

As explained above in Section III.a.1, each TA Grant recipient must submit Form SF-425 

(Federal Financial Report) to Treasury semiannually as well as a final Form SF-425 no later than 

120 calendar days after the end date of the period of performance. The following are details 

regarding the annual and final reports that TA Grant recipients must also submit to Treasury. 

a. Annual TA Project Progress and Outcomes Reports 

TA Grant recipients must provide multiple categories of information in their Annual TA Project 

Progress and Outcomes Reports during the award period of performance for the 12-month period 

covered by the report. The tables below specify all data elements required, as well as the 

frequency required for each category of information. In addition, TA Grant recipients must 

submit a brief narrative update on the TA recipient’s TA plan that describes how the recipient’s 

TA Grant implementation is progressing, including updates on the structure and offerings of 

TA services if it has changed from the original TA plan submission.10 Table 2 indicates the 

frequency of reporting for each category. 

Table 2. Annual Report Information and Frequency 

Category of Information Reporting Frequency

TA Provider Data (see 

Table 3 below) 

Data only must be reported one time for each TA provider. If 

there are updates to previously reported information, including 

“TA Services Provided” and “Amount of TA Grant Program 

Funds Budgeted,” the recipient may submit updates to those 

data elements, along with a statement that all other data 

elements remain unchanged. 

Eligible Beneficiary Data (if 

applicable) (see Table 4 

below) 

Data must be reported once for each business that receives 

TA services (except for attendees as a classroom-style TA 

services event). If a business receives more than one 

TA service, please report each service separately. For example, 

10 Note that certain changes to a recipient’s TA Grant require an amendment to the SSBCI TA Grant Agreement. 

Treasury intends to publish procedures that specify when an amendment is required. 
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if a business receives legal services in one month and then 

accounting services in the following month, the legal services 

should be reported as “TA Service 1” and the accounting 

services as “TA Service 2.” If a business receives a TA service 

that spans annual reporting periods, the continuing TA services 

may be reported in a subsequent annual reporting period, but 

should specify that the service is a continuing one in the “Brief 

Description” field for the relevant TA service.

Classroom-Style TA 

Services (if applicable) (see 

Table 5 below)

Data must be reported once for each classroom-style TA event. 

In addition, TA Grant recipients must provide a Privacy Notice and Privacy Act Statement (see 

Appendix 1) to those from whom they collect data, or cause the persons or entities that collect 

this data directly to provide the Privacy Notice and Privacy Act Statement.

The demographics-related data elements may only be collected and used for purposes of the 

TA Grant Program and must not be used for any other purposes (e.g., marketing, sale to 

third-parties). The demographics-related information must not be used in a manner that violates 

any applicable anti-discrimination laws, including, but not limited to, the laws specified in 

Schedule 1, Section 2. c of the SSBCI TA Grant Agreement “Compliance with Applicable Law 

and Regulations.” TA Grant Program recipients must establish processes to inform those from 

whom they collect data of this limited usage when these data elements are collected. Each 

recipient shall establish data privacy and security requirements for the demographic-related 

information described in Table 4 that include appropriate measures to ensure that the privacy of 

the individuals is protected. A sample demographic data collection form that can be used to

collect these data elements, with instructions for how the sample form should be used is included 

as Appendix 2 below. This sample form will be a useful tool for recipients.
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Table 3: TA Provider Data

Data Element Description

TA Provider Enter the name of the TA provider.

Relationship to TA Grant Indicate which category applies to the TA provider:

-TA Grant recipient

-TA Grant subrecipient – entity of TA Grant recipient

(including political subdivisions) 

-TA Grant subrecipient – legal, accounting, or financial 

advisory firm 

-TA Grant contractor – legal, accounting, or financial 

advisory firm

TA Provider Type Indicate what type of entity the TA provider is (if multiple 

types apply, choose the one that best describes the TA 

provider): 

-State entity (including political subdivisions) 

-Institution of higher education-affiliated entity, including 

community colleges 

-For-profit entity 

-Non-profit entity

-Other

Other TA Provider Type Text field for a description if selected “Other” for the data 

element “TA Provider Type.”
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Data Element Description

Self-Certified SEDI-Owned 

Business TA Provider

Indicate whether the TA provider self-certified that it is a 

SEDI-owned business. Select all categories in groups (1) 

through (4) that apply, including all subcategories in group 

(1) that apply: 

-(1) TA provider self-certified it 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)

-membership of an “underserved community” as defined 

in Executive Order 13985 (see the definition of 

“SEDI-owned business” in Section II above)

-(2) TA provider self-certified it 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)

-(3) TA provider self-certified that it will build, open, or 

operate a location in a CDFI Investment Area, as defined in 

12 C.F.R. § 1805.201(b)(3)(ii)

-(4) TA provider self-certified that it is located in a 

CDFI Investment Area, as defined in 12 C.F.R. 

§ 1805.201(b)(3)(ii)

-The TA provider did not certify
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Data Element Description

TA Services Provided Indicate the types of TA services the TA provider provides (if 

multiple types apply, select all that apply):

-Legal services: Assisting with business formation or 

adopting corporate governance documents

-Legal services: Obtaining needed registrations, licenses, 

filings, and certifications

-Legal services: Advising on, or preparing documents for, the 

business to enter into contracts

-Legal services: Legal services related to the business 

obtaining capital from investors, such as the development of 

financial instruments, investment term sheets, purchase 

agreements, and shareholder rights agreements

-Legal services: Legal services related to a transfer of 

ownership interests in a business, including employee stock 

ownership plans

-Legal services: Other

-Accounting services: Preparing audits, financial statements, 

or business records

-Accounting services: Digitizing financial records

-Accounting services: Advisory services or training regarding 

accounting practices, recordkeeping, or accounting software

-Accounting services: Other

-Financial advisory services: Assisting with the establishment 

of banking relationships or other financial services

-Financial advisory services: Assisting with applications for 

government small business programs, including preparing

financial analyses

-Financial advisory services: Identifying sources of credit, 

capital, grants, and other financing

-Financial advisory services: Advising on factors that may 

impede access to business financing 

-Financial advisory services: Advising on financial 

management

-Financial advisory services: Developing presentations to 

potential investors, financial models, and business plan

-Financial advisory services: Other

Description of Other TA 

Services

Text field for a description if selected “Legal Services: 

Other,” “Accounting services: Other,” or “Financial advisory 

services: Other” for the data element “TA Services Provided.” 

Amount of TA Grant Funds 

Budgeted

Amount of TA Grant funds budgeted for the TA provider.
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Table 4. Eligible Beneficiary Data (if applicable) 

Data Element Description

TA Provider Enter the name of the TA provider.

Eligible Beneficiary Identifier Name of the business that is the eligible beneficiary. If the 

eligible beneficiary prefers not to be identified by name, enter 

an alphanumeric or numeric code that serves as an anonymous 

identifier for the eligible beneficiary. Do not provide a Social 

Security number as an identifier. 

Eligible Beneficiary Street 

Address 

Enter the street address of the eligible beneficiary. 

If the eligible beneficiary business does not provide an 

address or prefers not to respond, enter “None provided.” 

Eligible Beneficiary City City of the eligible beneficiary.

Eligible Beneficiary State State of the eligible beneficiary. 

Eligible Beneficiary Zip Code Zip code of the eligible beneficiary. 

NAICS Code 2017 North American Industry Classification System 

(NAICS) code for the eligible beneficiary’s industry. Each 

industry sector is defined by the U.S. Census Bureau; see 

https://www.census.gov/programs-surveys/economiccensus/guidance/understanding-naics.html#par_textimage_1).

If multiple NAICS codes apply, choose the one that best 

describes the eligible beneficiary. 

Full-Time Equivalent 

Employees 

The eligible beneficiary’s full-time equivalent employees 

(FTEs), rounded to the nearest whole number, at the time 

TA services are provided. This is determined by adding the 

number of full-time employees and the number of part-time 

and seasonal employees as a fraction of a full-time employee. 

For example, if a business has 100 employees working 

full-time (assume a full-time week of 40 hours) and 

50 employees working 20 hours per week, the total number of 

FTEs would be 125. For seasonal employees, the FTE count is 

based on a 2,080-hour year, so that an employee who works 

520 hours per year counts as 0.25 FTEs. 

Volunteers (i.e., individuals who receive no compensation, 

including no in-kind compensation, for work performed) are 

not considered employees. 

This data element can be used to assess whether a business 

qualifies as a VSB. 
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Data Element Description

VSB Indicate whether the eligible beneficiary’s business is a VSB.

-Yes

-No

The TA Grant recipient may reasonably determine that a 

business is a VSB based on the FTE number provided by the 

business or a certification that the business meets the 

definition of VSB. 

Self-Certified SEDI-Owned

Business Status

Indicate whether the eligible beneficiary self-certified that it is 

a SEDI-owned business. Select all categories in groups (1) 

through (4) that apply:

-(1) Eligible beneficiary self-certified it 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 netzero economy or deindustrialization)

-membership of an “underserved community” as defined in 

Executive Order 13985 (see the definition of “SEDI-owned

business” in Section II above)

-(2) Eligible beneficiary self-certified it 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)

-(3) Eligible beneficiary self-certified that it will build, open, 

or operate a location in a CDFI Investment Area, as defined in 

12 C.F.R. § 1805.201(b)(3)(ii)

-(4) Eligible beneficiary self-certified that it is located in a 

CDFI Investment Area, as defined in 12 C.F.R. § 

1805.201(b)(3)(ii)

-Eligible beneficiary did not certify
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Data Element Description

Minority-Owned or Controlled 

Business Status

Indicate whether the eligible beneficiary is a minority-owned 

or controlled business: 

-Yes

-No

-Prefer not to respond

-The business did not answer

Women-Owned or Controlled 

Business Status

Indicate whether the eligible beneficiary is a women-owned or 

controlled business: 

-Yes

-No

-Prefer not to respond

-The business did not answer

Veteran-Owned or Controlled 

Business Status

Indicate whether the eligible beneficiary is a veteran-owned or 

controlled business: 

-Yes

-No

-Prefer not to respond

-The business did not answer

Race of Principal Owners Indicate the race categories with which the principal owner or 

principal owners identify (check all that apply):

11

-American Indian or Alaska Native 

-Asian 

 --Indian 

 --Chinese 

 --Filipino 

 --Japanese 

 --Korean 

 --Vietnamese 

 --Asian (Other)

-Black or African American 

-Native Hawaiian or Other Pacific Islander 

 --Guamanian or Chamorro 

 --Native Hawaiian 

 --Samoan 

 --Pacific Islander (Other) 

-White

-Prefer not to respond

-The business did not answer

11 Treasury’s interim final rule on demographic data reporting contemplated that demographic data would be 

collected and reported “for each principal owner of the business.” See State Small Business Credit Initiative; 

Demographics-Related Reporting Requirements, 87 Fed. Reg. 13628, 13634 (Mar. 10, 2022), codified at 31 C.F.R. 

Part 35. For purposes of this reporting guidance, Treasury will consider the requirement in that rule to be satisfied if 

a recipient reports principal owner demographic data in the form set out in this table (i.e., where categories are 

checked as they apply to one or more principal owners of a business, without principal owner demographics being 

reported separately for each principal owner).
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Data Element Description

Ethnicity of Principal Owners Indicate the following ethnicity categories with which the 

principal owner or principal owners identify (check all that 

apply): 

-Hispanic or Latino/a 

-Not Hispanic or Latino/a

-Prefer not to respond

-The business did not answer

Middle Eastern or North 

African Ancestry of Principal 

Owners

Indicate the following ancestry categories with which the 

principal owner or principal owners identify (check all that 

apply): 

-Middle Eastern or North African 

-Not Middle Eastern or North African 

-Prefer not to respond 

-The business did not answer

Gender of Principal Owners Indicate the following gender categories with which the 

principal owner or principal owners identify (check all that 

apply): 

-Female

-Male

-Nonbinary 

-Prefer to self-describe

-Prefer not to respond 

-The business did not answer

Gender of Principal Owners –

Self-Identification

Text field for description if selected “Prefer to self-describe” 

in the data element “Gender of a Principal Owners.”

Sexual Orientation of

Principal Owners

Indicate the following sexual orientation categories with 

which the principal owner or principal owners identify (check 

all that apply): 

-Gay or lesbian 

-Bisexual 

-Straight, that is, not gay, lesbian, or bisexual 

-Something else 

-Prefer not to respond 

-The business did not answer

Veteran Status of Principal 

Owners

Indicate the following categories with which the principal 

owner or principal owners identify (check all that apply): 

-Veteran

-Non-veteran

-Prefer not to respond 

-The business did not answer

TA Services Provided to the 

Eligible Beneficiary 

Provide the following information for TA services 

provided to the eligible beneficiary. If more than one 

discrete TA service is provided to an eligible beneficiary, 

the TA provider can report additional TA services in the 

fields for TA services 2 through 4. 
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Data Element Description

Primary Purpose – TA Service 

1

Indicate the primary purpose of TA service 1: 

-Legal services: Assisting with business formation or adopting 

corporate governance documents

-Legal services: Obtaining needed registrations, licenses, 

filings, and certifications

-Legal services: Advising on, or preparing documents for, the 

business to enter into contracts

-Legal services: Legal services related to the business 

obtaining capital from investors, such as the development of 

financial instruments, investment term sheets, purchase 

agreements, and shareholder rights agreements

-Legal services: Legal services related to a transfer of 

ownership interests in a business, including employee stock 

ownership plans

-Legal services: Other

-Accounting services: Preparing audits, financial statements, 

or business records

-Accounting services: Digitizing financial records

-Accounting services: Advisory services or training regarding 

accounting practices, recordkeeping, or accounting software.

-Accounting services: Other

-Financial advisory services: Assisting with the establishment 

of banking relationships or other financial services

-Financial advisory services: Assisting with applications for 

government small business programs, including preparing

financial analyses

-Financial advisory services: Identifying sources of credit, 

capital, grants, and other financing

-Financial advisory services: Advising on factors that may 

impede access to business financing 

-Financial advisory services: Advising on financial 

management

-Financial advisory services: Developing presentations to 

potential investors, financial models, and business plans

-Financial advisory services: Other

Primary Purpose of 

TA Service 1 – Other 

Text field for description if selected “Legal Services: Other,” 

“Accounting services: Other,” or “Financial advisory services: 

Other” for the data element “Primary Purpose – TA Service 

1.”

TA Service 1 – Brief 

Description 

Provide a brief, descriptive overview of TA service 1. 
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Data Element Description

Style – TA Service 1 Indicate how the TA provider provided TA service 1. 

-One-on-one (TA provider worked individually with eligible 

beneficiary)

-Small-group (TA provider worked with a group to address 

specific small business issues (generally 2-10 people, but 

number may vary))

-Cohort (a group of eligible beneficiaries advanced through an 

educational program or curriculum)

-Other

Description of Other Style –

TA Service 1 

Text field for a description if selected “Other” for the data 

element “Style – TA Service 1.”

Hours – TA Service 1 Number of hours spent providing TA Service 1 to the eligible 

beneficiary. 
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Data Element Description

Primary Purpose –TA Service 

2 (if applicable)

Indicate the primary purpose of TA service 2: 

-Legal services: Assisting with business formation or adopting 

corporate governance documents

-Legal services: Obtaining needed registrations, licenses, 

filings, and certifications

-Legal services: Advising on, or preparing documents for, the 

business to enter into contracts

-Legal services: Legal services related to the business 

obtaining capital from investors, such as the development of 

financial instruments, investment term sheets, purchase 

agreements, and shareholder rights agreements

-Legal services: Legal services related to a transfer of 

ownership interests in a business, including employee stock 

ownership plans

-Legal services: Other

-Accounting services: Preparing audits, financial statements, 

or business records

-Accounting services: Digitizing financial records

-Accounting services: Advisory services or training regarding 

accounting practices, recordkeeping, or accounting software

-Accounting services: Other

-Financial advisory services: Assisting with the establishment 

of banking relationships or other financial services

-Financial advisory services: Assisting with applications for 

government small business programs, including preparing

financial analyses

-Financial advisory services: Identifying sources of credit, 

capital, grants, and other financing

-Financial advisory services: Advising on factors that may 

impede access to business financing 

-Financial advisory services: Advising on financial 

management

-Financial advisory services: Developing presentations to 

potential investors, financial models, and business plans

-Financial advisory services: Other

Primary Purpose of 

TA Service 2 – Other 

Text field for description if selected “Legal Services: Other,” 

“Accounting services: Other,” or “Financial advisory services: 

Other” for the data element “Primary Purpose – TA Service 

2.”

TA Service 2 – Brief 

Description 

Provide a brief, descriptive overview of TA service 2. 
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Data Element Description

Style – TA Service 2 Indicate how the TA provider provided TA service 2. 

-One-on-one (TA provider worked individually with eligible 

beneficiary)

-Small-group (TA provider worked with a group to address 

specific small business issues (generally 2-10 people, but 

number may vary))

-Cohort (a group of eligible beneficiaries advanced through an 

educational program or curriculum)

-Other

Description of Other Style –

TA Service 2 

Text field for a description if selected “Other” for the data 

element “Style – TA Service 2.”

Hours – TA Service 2 Number of hours spent providing TA Service 2 to the eligible 

beneficiary. 
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Data Element Description

Primary Purpose –TA Service 

3 (if applicable)

Indicate the primary purpose of TA service 3: 

-Legal services: Assisting with business formation or adopting 

corporate governance documents

-Legal services: Obtaining needed registrations, licenses, 

filings, and certifications

-Legal services: Advising on, or preparing documents for, the 

business to enter into contracts

-Legal services: Legal services related to the business 

obtaining capital from investors, such as the development of 

financial instruments, investment term sheets, purchase 

agreements, and shareholder rights agreements

-Legal services: Legal services related to a transfer of 

ownership interests in a business, including employee stock 

ownership plans

-Legal services: Other

-Accounting services: Preparing audits, financial statements, 

or business records

-Accounting services: Digitizing financial records

-Accounting services: Advisory services or training regarding 

accounting practices, recordkeeping, or accounting software

-Accounting services: Other

-Financial advisory services: Assisting with the establishment 

of banking relationships or other financial services

-Financial advisory services: Assisting with applications for 

government small business programs, including preparing

financial analyses

-Financial advisory services: Identifying sources of credit, 

capital, grants, and other financing

-Financial advisory services: Advising on factors that may 

impede access to business financing 

-Financial advisory services: Advising on financial 

management

-Financial advisory services: Developing presentations to 

potential investors, financial models, and business plans

-Financial advisory services: Other

Primary Purpose of 

TA Service 3 – Other 

Text field for description if selected “Legal Services: Other,” 

“Accounting services: Other,” or “Financial advisory services: 

Other” for the data element

“Primary Purpose – TA Service 3.”

TA Service 3 – Brief 

Description 

Provide a brief, descriptive overview of TA service 3. 
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Data Element Description

Style – TA Service 3 Indicate how the TA provider provided TA service 3. 

-One-on-one (TA provider worked individually with eligible 

beneficiary)

-Small-group (TA provider worked with a group to address 

specific small business issues (generally 2-10 people, but 

number may vary))

-Cohort (a group of eligible beneficiaries advanced through an 

educational program or curriculum)

-Other

Description of Other Style –

TA Service 3 

Text field for a description if selected “Other” for the data 

element “Style – TA Service 3.”

Hours – TA Service 3 Number of hours spent providing TA Service 3 to the eligible 

beneficiary. 
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Data Element Description

Primary Purpose –TA Service 

4 (if applicable)

Indicate the primary purpose of TA service 4: 

-Legal services: Assisting with business formation or adopting 

corporate governance documents

-Legal services: Obtaining needed registrations, licenses, 

filings, and certifications

-Legal services: Advising on, or preparing documents for, the 

business to enter into contracts

-Legal services: Legal services related to the business 

obtaining capital from investors, such as the development of 

financial instruments, investment term sheets, purchase 

agreements, and shareholder rights agreements

-Legal services: Legal services related to a transfer of 

ownership interests in a business, including employee stock 

ownership plans

-Legal services: Other

-Accounting services: Preparing audits, financial statements, 

or business records

-Accounting services: Digitizing financial records

-Accounting services: Advisory services or training regarding 

accounting practices, recordkeeping, or accounting software

-Accounting services: Other

-Financial advisory services: Assisting with the establishment 

of banking relationships or other financial services

-Financial advisory services: Assisting with applications for 

government small business programs, including preparing

financial analyses

-Financial advisory services: Identifying sources of credit, 

capital, grants, and other financing

-Financial advisory services: Advising on factors that may 

impede access to business financing 

-Financial advisory services: Advising on financial 

management

-Financial advisory services: Developing presentations to 

potential investors, financial models, and business plans

-Financial advisory services: Other

Primary Purpose of 

TA Service 4 – Other 

Text field for description if selected “Legal Services: Other,” 

“Accounting services: Other,” or “Financial advisory services: 

Other” for the data element “Primary Purpose – TA Service 

4.”

TA Service 4 – Brief 

Description 

Provide a brief, descriptive overview of TA service 4. 
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Data Element Description

Style – TA Service 4 Indicate how the TA provider provided TA service 4. 

-One-on-one (TA provider worked individually with eligible 

beneficiary)

-Small-group (TA provider worked with a group to address 

specific small business issues (generally 2-10 people, but 

number may vary))

-Cohort (a group of eligible beneficiaries advanced through an 

educational program or curriculum)

-Other

Description of Other Style –

TA Service 4 

Text field for a description if selected “Other” for the data 

element “Style – TA Service 4.”

Hours – TA Service 4 Number of hours spent providing TA Service 4 to the eligible 

beneficiary. 

Small Business Program 

Referral

If the TA provider made a referral to a small business program 

with respect to the eligible beneficiary, check all that apply: 

-SSBCI-supported lending program

-SSBCI-supported equity/venture capital program 

-Other federal small business program

-Other small business program

-N/A 

Name of Small Business 

Program

If the TA provider made a referral to a small business program 

with respect to the eligible beneficiary, text field to specify the 

name of each small business program to which the eligible 

beneficiary was referred.

Referral to Source of Capital If the TA provider made a referral to a potential source of 

capital with respect to the eligible beneficiary, check all that 

apply:

-CDFI bank, thrift, or depository institution holding company

-Non-CDFI community bank

-Other bank, thrift, or depository institution holding company 

-CDFI loan fund

-Non-CDFI credit union

-Nonbank lender or nonbank payment services provider

-Non-CDFI debt or loan fund

-Growth equity capital fund

-Angel investor or angel fund

-For-profit venture capital fund

-Nonprofit venture capital fund or venture/entrepreneurial 

development organization

-Corporate venture capital fund

-CDFI venture capital fund

-University/technology transfer office

-Other
SSBCI TA Grant Program Reporting Guidance 

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Data Element Description

Description of Other Lender or 

Other Investor

Text field for a description of the type of lender or investor if 

selected “Other lender” or “Other investor” for the data 

element “Source of Capital Referral.” Note that the TA 

provider is not required to specify the name of the lender or 

investor.

Table 5: Classroom-Style TA Services (if applicable)

The TA Grant recipient must report the information below for each classroom-style TA service 

event.

Data Element Description

Classroom-Style

TA Services

Provide the following information for each Classroom-Style TA 

Service Event

Classroom-Style TA 

Service Event – 

Primary Purpose 

Indicate the primary purpose of the classroom-style TA service event: 

-Legal services: Assisting with business formation or adopting 

corporate governance documents 

-Legal services: Obtaining needed registrations, licenses, filings, and 

certifications

-Legal services: Advising on, or preparing documents for, the business 

to enter into contracts 

-Legal services: Legal services related to the business obtaining capital 

from investors, such as the development of financial instruments, 

investment term sheets, purchase agreements, and shareholder rights 

agreements

-Legal services: Legal services related to a transfer of ownership 

interests in a business, including employee stock ownership plans 

-Legal services: Other

-Accounting services: Preparing audits, financial statements, or 

business records 

-Accounting services: Digitizing financial records 

-Accounting services: Advisory services or training regarding 

accounting practices, recordkeeping, or accounting software 

-Accounting services: Other

-Financial advisory services: Assisting with the establishment of 

banking relationships or other financial services 

-Financial advisory services: Assisting with applications for 

government small business programs, including preparing financial

analyses

-Financial advisory services: Identifying sources of credit, capital, 

grants, and other financing 

-Financial advisory services: Advising on factors that may impede 

access to business financing 

-Financial advisory services: Advising on financial management
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26

-Financial advisory services: Developing presentations to potential 

investors, financial models, and business plans 

-Financial advisory services: Other

Primary Purpose of 

Classroom-Style TA 

Service Event – 

Other 

Text field for description if selected “Legal Services: Other,” 

“Accounting services: Other,” or “Financial advisory services: Other” 

for the data element “Classroom-Style TA Service Event – Primary 

Purpose.”

Classroom-Style TA 

Service Event – 

Brief Description 

Provide a brief, descriptive overview of the classroom-style TA service 

event, including how the TA provider specifically targeted the event 

towards eligible beneficiaries. 

Classroom-Style TA 

Service Event – 

Attendees

Text field for the number of attendees that attended classroom-style TA 

service event. 

Classroom-Style TA 

Service Event - Date

Text field to provide the date of the classroom-style TA service event. 

b. Final TA Project Progress and Outcomes Report

TA Grant recipients must provide the following in their Final TA Project Progress and Outcomes

Report, which is due to Treasury no later than 120 calendar days after the end date of the award 

period of performance. 

This report will consist of a narrative containing the following: 

• An assessment of progress made toward achieving each of the recipient’s performance 

goals established under the TA plan, including output measures and benchmarks 

described in the recipient’s TA plan. 

• A data-driven assessment of how the recipient’s TA Grant funds targeted the needs of 

eligible beneficiaries.

• An evaluation of the recipient’s TA providers, including: 

o An overview of the activities undertaken by TA providers, and 

o The extent to which the TA providers achieved economic benefits to SEDI-owned 

businesses and VSBs according to the economic benefit ratio (see Section V.b of the 

SSBCI TA Program Guidelines “TA Provider Requirement: Connection to Economic 

Benefits”). 

• A description of how the recipient’s overall TA project supported or complemented 

relevant small business programs. 

• An assessment of the recipient’s strategy and efforts to reach eligible beneficiaries. 

• A description of how the recipient identified gaps and opportunities in the recipient’s 

ability to fulfill and achieve the goals of the TA plan and how the recipient addressed 

those issues. This should include any updates on the structure and offerings of 

TA services as the award progressed to meet the needs of eligible beneficiaries.

• Any other material information, which may include expected and actual benefits to 

eligible beneficiaries of the TA Grant. 

In addition, a final Form SF-425 must be submitted to Treasury no later than 120 calendar days 

after the end date of the period of performance as set forth in the SSBCI TA Grant Agreement. 
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Section VI. Reporting Subawards and Executive Compensation, Maintenance of and 

Access to Records, and Increase of Frequency and Scope of Reporting

In accordance with Schedule 1, Section 2.b.iii of the SSBCI TA Grant Agreement on reporting 

subawards and executive compensation, TA Grant recipients must report as part of their 

registration profile at https://www.sam.gov by the end of the month following the month in 

which this award is made, and annually thereafter, the names and total compensation for their 

five most highly compensated executives for the preceding completed fiscal year, if: (1) the total 

Federal funding authorized to date under this Federal award equals or exceeds $30,000 as 

defined in 2 CFR 170.320; (2) in the preceding fiscal year, the TA Grant recipient received 

(a) 80 percent or more of their annual gross revenues from Federal procurement contracts (and 

subcontracts) and Federal financial assistance subject to the Transparency Act, as defined at 

2 CFR 170.320 (and subawards), and (b) $25,000,000 or more in annual gross revenues from 

Federal procurement contracts (and subcontracts) and Federal financial assistance subject to the 

Transparency Act, as defined at 2 CFR 170.320 (and subawards); and (3) the information is not 

otherwise public. 

TA Grant recipients are required to report in http://www.fsrs.gov on subawards that equal or 

exceed $30,000 in TA Grant funds no later than the end of the month following the month in 

which the obligation was made. (For example, if the obligation was made on November 7, 2010, 

the obligation must be reported by no later than December 31, 2010). For more information, see 

the award term at 2 C.F.R. Part 170, Appendix A, which is incorporated into the SSBCI TA

Grant Agreement. 

Schedule 1, Section 4 of the SSBCI TA Grant Agreement contains information regarding records 

maintenance and access requirements that TA Grant recipients must comply with under their 

TA Grants In particular, TA Grant recipients should maintain documentation evidencing their 

determination that a TA provider that is a contractor or subrecipient, as applicable, is a legal, 

accounting, or financial advisory firm. Treasury has published an FAQ specifying that for 

purposes of the TA Grant Program, a legal accounting or financial advisory firm is an entity that 

meets at least one of the following criteria: 

(a) A primary purpose of the or a central part to entity’s mission is to provide legal, 

accounting, and/or financial advisory services, 

(b) The entity regularly markets or publicizes itself as providing legal, accounting, and/or 

financial advisory services, or 

(c) At least 25% of the entity’s revenues or staff are dedicated to providing legal, 

accounting, and/or financial advisory services.12 

In making these determinations, TA Grant recipients may, but are not required to, require entities 

to self-certify that they meet the definition set out in the appliable FAQ. 

Treasury may unilaterally increase the frequency and scope of a TA Grant recipient’s reporting 

requirements if Treasury finds the recipient to be high-risk. To determine whether a TA Grant 

recipient is considered high-risk, Treasury will apply a risk evaluation approach that is consistent 

12 SSBCI FAQs are published on Treasury’s website at State Small Business Credit Initiative (SSBCI) | U.S. 

Department of the Treasury. 
SSBCI TA Grant Program Reporting Guidance

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28

with the principles set forth in 2 C.F.R. § 200.206. Treasury may find a TA Grant recipient to be 

high-risk before or after Treasury executes the SSBCI TA Grant Agreement.

Because TA Grant recipients and TA providers will be receiving sensitive information, Treasury 

strongly encourages TA Grant recipients and TA providers to establish robust protections against 

data breaches and misuse of sensitive information and to comply with all applicable privacy laws

as set forth in Schedule 1, Section 9 of the SSBCI TA Grant Agreement. 2 C.F.R. § 200.303(e) 

requires that TA Grant recipients and subrecipients take reasonable measures to safeguard 

protected PII and other information that Treasury or the TA Grant recipient designates as 

sensitive or the TA Grant recipient considers sensitive consistent with applicable federal, state, 

local, and Tribal laws regarding privacy and responsibility over confidentiality.
SSBCI TA Grant Program Reporting Guidance 

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Appendix 1

SSBCI Privacy Notice and Privacy Act Statement

Privacy Notice: 

Information from this collection will be shared with the U.S. Department of the Treasury 

(Treasury). Treasury will maintain a Privacy and Civil Liberties Impact Assessment that 

describes what Treasury will do with the information your business provides in connection with 

the SSBCI TA Grant program. It can be found on the Treasury website. If you have any 

questions about this document, please email Privacy@Treasury.gov. 

Privacy Act Statement for Sole Proprietorships:

The Privacy Act of 1974 (Privacy Act) protects certain information that the federal government 

has about “individuals” (United States citizens and lawfully admitted permanent residents). The 

Privacy Act does not generally apply to businesses, but some federal courts have found that this 

law applies to sole proprietors (they are deemed “individuals” under the Privacy Act). If you, as 

the applicant, are a sole proprietor, you may have rights under the Privacy Act. 

Authority: Small Business Jobs Act of 2010 (SBJA), Title III, 12 U.S.C. § 5701 et seq., as 

amended by the American Rescue Plan Act of 2021 (ARPA), section 3301; Executive Order No. 

13985, Advancing Racial Equity and Support for Underserved Communities Through the 

Federal Government, 86 Fed. Reg. 7009 (January 25, 2021); and Interim Final Rule, State Small 

Business Credit Initiative; Demographics-Related Reporting Requirements, 87 Fed. Reg. 13628

(March 10, 2022).

Purpose: Information from this collection will be shared with Treasury. This information will be 

shared with Treasury so it can conduct oversight to ensure compliance with the terms and 

conditions of the SSBCI TA Grant Agreement executed in the recipient in connection with its 

TA Grant including federal laws with requirements related to nondiscrimination and 

nondiscriminatory uses of federal funds. Treasury also receives this information (including any 

demographic information provided), to comply with reporting requirements under the authorities 

listed above, to advance fairness and opportunity in underserved communities in the allocation of 

federal resources, and to analyze the distribution of resources in federal programs, including to 

assess program effectiveness and outcomes. 

Routine Uses: The information you furnish may be shared in accordance with the routine uses 

outlined in Treasury .013, Department of the Treasury Civil Rights Complaints, Compliance 

Reviews, and Fairness in Federal Programs Files System of Records Notice (SORN), 88 Fed. 

Reg. 12439; Treasury .015, General Information Technology Access Account Records, 85 Fed. 

Reg. 73353; and Treasury .017, Correspondence and Contact Information, 81 Fed. Reg. 

78266. For example, one routine use under Treasury .013 is to disclose pertinent information to 

appropriate agencies when Treasury becomes aware of a potential violation of civil or criminal 

law. Under this routine use, Treasury may disclose demographic information to the appropriate 

agencies if Treasury becomes aware of a violation of applicable antidiscrimination laws. More 

information about this and other routine uses can be found in the SORNs listed above, updates to 

which may be periodically noted on Treasury’s website. 
SSBCI TA Grant Program Reporting Guidance 

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30 

Disclosure: Providing this information is voluntary. However, failure to furnish the requested 

information may result in the denial of your request to receive SSBCI-supported technical 

assistance. Providing demographic information is optional. If you decline to provide this 

information, it will not adversely affect your eligibility to receive SSBCI-supported technical 

assistance under Treasury’s SSBCI TA Grant Program rules and guidance. 
SSBCI TA Grant Program Reporting Guidance 

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Appendix 2

SSBCI TA Grant Program Sample Form for Demographics-Related Data

This sample form may be used by a TA Grant recipient and/or its subrecipients and TA providers 

to obtain demographics-related data. This sample form is provided for illustrative purposes as a 

tool for recipients. A recipient may adopt its own form, provided that the form complies with all 

SSBCI requirements. 

Legal name of business: __________________________________________ 

The business has received technical assistance under the State Small Business Credit Initiative 

Technical Assistance Grant Program (SSBCI TA Grant Program), which is a federal program 

that provides grants to eligible recipients to carry out a technical assistance plan to provide legal, 

accounting, and financial advisory services to small businesses that are applying, have previously 

applied to, or plan to apply to an SSBCI Capital Program or other government program that 

supports small businesses. 

Filling out this form and providing the demographic information requested therein is optional; 

the business not required to provide the requested information but is encouraged to do so. The 

entity collecting this information cannot discriminate on the basis of whether an applicant 

provides the information requested in this form, or based on any information provided on this 

form. If you decline to provide the information requested in this form, it will not adversely affect 

your ability to receive technical assistance. 

The demographics-related information collected can only be used for purposes of the 

SSBCI TA Grant 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 anti-discrimination laws, including, but not limited to, the following authorities: 

• Title VI of the Civil Rights Act of 1964 (Title VI), 42 U.S.C. § 2000d-1 et seq., and 

Treasury’s implementing regulations, 31 C.F.R. part 22; 

• Section 504 of the Rehabilitation Act of 1973 (Section 504), 29 U.S.C. § 794; 

• Title IX of the Education Amendments of 1972 (Title IX), 20 U.S.C. § 1681 et seq., and 

Treasury’s implementing regulations, 31 C.F.R. part 28; 

• the Age Discrimination Act of 1975, 42 U.S.C. § 6101 et seq., and Treasury’s 

implementing regulations at 31 C.F.R. part 23. 

If you believe you were discriminated against in connection with the provision of the information 

provided on this form, contact: Director, Office of Civil Rights and Equal Economic 

Opportunity, U.S. Department of the Treasury, 1500 Pennsylvania Ave, N.W., Washington, DC 

20220, or by email at crcomplaints@treasury.gov. 

PAPERWORK REDUCTION ACT NOTICE - OMB Control Number [_____________] 
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An agency may not conduct or sponsor, and a person is not required to respond to, a collection of

information unless it displays a valid control number assigned by OMB.

The business is encouraged to answer all of the questions below. This information is being 

collected to help ensure that communities’ small business technical assistance and access to 

credit needs are being fulfilled and allow SSBCI to analyze the populations that SSBCI TA 

Grant Program funding is benefiting.

1. Minority-owned or controlled business status

For purposes of this form, minority individual means a natural person who identifies as 

American Indian or Alaska Native; Asian American; Black or African American; Native 

Hawaiian or Other Pacific Islander; Hispanic or Latino/a; or one or more than one of these 

groups. 

For purposes of this form, an applicant is a minority-owned or controlled business if the 

business meets one or more of the following: 

(1) if privately owned, 51 percent or more is owned by minority individuals; 

(2) if publicly owned, 51 percent or more of the stock is owned by minority individuals; 

(3) in the case of a mutual institution, a majority of the board of directors, account holders, and 

the community which the institution services is predominantly comprised of minority 

individuals; or 

(4) one or more minority individuals have the power to exercise a controlling influence over 

the business

Is the business a minority-owned or 

controlled business? 

Yes No Prefer not to 

respond

2. Women-owned or controlled business status

For purposes of this form, an applicant is a women-owned or controlled business if the 

business meets one or more of the following: 

(1) if privately owned, 51 percent or more is owned by females; 

(2) if publicly owned, 51 percent or more of the stock is owned by females; 

(3) in the case of a mutual institution, a majority of the board of directors, account holders, and 

the community which the institution services is predominantly comprised of females; or 

(4) one or more individuals who are females have the power to exercise a controlling influence 

over the business.

Is the business a women-owned or controlled 

business?

Yes No Prefer not to 

respond

3. Veteran-owned or controlled business status

For purposes of this form, an applicant is a veteran-owned or controlled business if the 

business meets one or more of the following: 

(1) if privately owned, 51 percent or more is owned by veterans; 

(2) if publicly owned, 51 percent or more of the stock is owned by veterans; 

(3) in the case of a mutual institution, a majority of the board of directors, account holders, and 

the community which the institution services is predominantly comprised of veterans; or 

(4) one or more individuals who are veterans have the power to exercise a controlling 

influence over the business.

Is the business a veteran-owned or controlled 

business?

Yes No Prefer not to 

respond
SSBCI TA Grant Program Reporting Guidance 

DRAFT as of June 7, 2023 

33 

The business is encouraged to answer the questions below for its principal owners. 

This information is being collected to help ensure that communities’ small business technical 

assistance and access to credit needs are being fulfilled and allow SSBCI to analyze the 

populations that SSBCI TA Grant funding is benefiting. 

For purposes of this form, a principal owner of the business is a natural person who, directly or 

indirectly, through any contract, arrangement, understanding, relationship or otherwise, owns 

25 percent or more of the equity of the business. If a trust owns, directly or indirectly, through 

any contract, arrangement, understanding, relationship or otherwise, 25 percent or more of the 

equity interests of the business, the trustee is a principal owner. 

If an applicant has more than one principal owner, the business is encouraged to check all of the 

categories that apply for those principal owners. In this case, the business is not required to 

submit a separate copy of this table for each principal owner. In addition, do not provide the 

name of the principal owner or otherwise identify which principal owner corresponds to each 

reported category.

1. Ethnicity

Hispanic or Latino/a Not Hispanic or Latino/a 

Prefer not to respond

2. Race (select all that apply)

American Indian or Alaska Native Black or African American

Asian Native Hawaiian or Other Pacific Islander

 Indian Guamanian or Chamorro 

 Chinese Native Hawaiian

 Filipino Samoan

 Japanese Pacific Islander (Other)

 Korean White

 Vietnamese Prefer not to respond 

 Asian (Other)

3. Middle Eastern or North African Ancestry 

Middle Eastern or North African Not Middle Eastern or North African 

Prefer not to respond

4. Gender

Female

Male

Nonbinary 

Prefer to self-describe 

__________________________________ 

Prefer not to respond

5. Sexual Orientation 

Gay or lesbian 

Bisexual

Straight, that is, not gay, lesbian, or bisexual 

Something else 

Prefer not to respond 

6. Veteran Status

Veteran Non-veteran

Prefer not to respond
SSBCI TA Grant Program Reporting Guidance

DRAFT as of June 7, 2023

34

Appendix 3

Certification required with SSBCI TA Grant Reports

The undersigned, on behalf of the SSBCI TA recipient specified below, hereby makes the 

following certifications:

1. By signing this report, I certify to the best of my knowledge and belief that the report is 

true, complete, and accurate, and the expenditures, disbursements and cash receipts are 

for the purposes and objectives set forth in the terms and conditions of the Federal award. 

I am aware that any false, fictitious, or fraudulent information, or the omission of any 

material fact, may subject me and the recipient to criminal, civil or administrative 

penalties for fraud, false statements, false claims or otherwise. (U.S. Code Title 18, 

Section 1001 and Title 31, Sections 3729–3730 and 3801–3812). 

2. The information, certifications, attachments, and other information provided by the 

recipient specified below to the U.S. Department of the Treasury related to its State 

Small Business Credit Initiative (SSBCI) TA Grant are true and correct and do not 

contain any materially false, fictitious, or fraudulent statement, nor any concealment or 

omission of any material fact.

3. I make these certifications after reasonable inquiry of people, systems, and other 

information available to the SSBCI TA recipient. 

4. The SSBCI TA recipient is implementing the award in accordance with the terms and 

conditions of its SSBCI TA grant agreement, including all applicable legal, regulatory, 

and program requirements, including the SSBCI statute (12 U.S.C. § 5701 et seq.), the 

U.S. Department of the Treasury’s SSBCI regulations, and SSBCI TA guidance to the 

best of the undersigned’s knowledge; and

5. The undersigned has authority to execute and deliver this certification on behalf of the 

SSBCI TA recipient.

IN WITNESS WHEREOF, this certificate has been duly executed on [ ] day of [ ], 202[ ]. 

[Name of Recipient] 

By: _______________________________ 

Name of Authorized Official/Representative: 

Title:
SSBCI TA Grant Program Reporting Guidance

DRAFT as of June 7, 2023

35

Appendix 4

Certification Required of an Agent for the Tribes

In the case of a non-Tribal entity or Tribal-affiliated entity (referred to as “Agent for the Tribes) 

that directly applies for and administers a TA Grant on behalf of a group of Tribal governments, 

the Agent for the Tribes (in its individual capacity) must certify to Treasury prior to application 

approval and upon submission of each required TA Grant Program report or request for 

additional disbursements of funding that: 

1. It is duly authorized to act as agent of each of the Tribal governments and of the group of 

Tribal governments for the purposes of the SSBCI TA Grant Program.

2. It is capable of fulfilling program requirements on behalf of each of the Tribal 

governments and the group of Tribal governments.

3. To the extent it is acting as an agent for the group of Tribal governments, it agrees to 

comply with all terms and conditions of the TA Grant Agreement, including the SSBCI 

statute, the TA Grant Program regulations, TA Grant Program guidance, and other 

applicable Federal laws and regulations including with respect to the requirements for 

reporting and use of funds.

4. To the extent that it is acting in its own capacity, it agrees to comply with all terms and 

conditions of the TA Grant Agreement, including the SSBCI statute, the TA Grant 

Program regulations, TA Grant Program guidance, and other applicable Federal laws and 

regulations including with respect to the requirements for reporting and use of funds as if 

it were a subrecipient.

5. To the extent that it is also implementing or will also implement an SSBCI capital 

program or TA grant for another jurisdiction (e.g., for a U.S. state), it has disclosed that 

relationship to the group of Tribal governments and has procedures in place to protect 

against any conflicts of interest that may arise. 

6. It is not debarred, suspended, or otherwise excluded from or ineligible for participation in 

Federal assistance programs or activities prior to obtaining any grant funds from Treasury 

per 31 CFR Part 19 and see also 2 CFR § 200.214.