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U.S. Department of the Treasury

State Small Business Credit Initiative

Capital Program Reporting Guidance

Revised February 21, 20241

Section I. Overview

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

Jobs Act of 2010, codified at 12 U.S.C. § 5701 et seq., to provide $10 billion to fund the State 

Small Business Credit Initiative (SSBCI) as a response to the economic effects of the COVID-19 

pandemic. SSBCI is a federal program administered by the Department of the Treasury

(Treasury) that was created to strengthen capital programs that support private financing to small 

businesses, including capital access programs (CAPs) and other credit support programs 

(OCSPs), of eligible jurisdictions (i.e., states, the District of Columbia, territories, Tribal 

governments, and eligible municipalities). 

This Capital Program Reporting Guidance details the reporting and document retention

requirements for jurisdictions that receive SSBCI funding (“participating jurisdictions”).

Treasury will create an online portal that participating jurisdictions must use to submit reporting 

data.2 Treasury will provide more information about the submission format in the coming 

months. This guidance may be updated periodically. Guidance regarding information that must 

be submitted at the end of the SSBCI program will be issued in the future. Furthermore, to 

increase the quality and comparability of the demographic data collected, Treasury has published

a sample demographic data collection form that we encourage SSBCI program providers to use.

Section II specifies the deadlines for participating jurisdictions to submit quarterly and annual 

reports. Section III sets forth definitions of terms used in this guidance. Sections IV and V

provide details regarding the information to be reported in quarterly and annual reports, which 

will support SSBCI implementation, monitoring, and compliance, as well as the assessment of 

outcomes of SSBCI-supported investments and loans. Section VI specifies additional 

requirements related to record retention and the frequency of reporting. 

Treasury may release public reports or data based on the information reported. 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 sensitive information such as 

commercial or financial information about businesses.

1 Capital Program Reporting Guidance was initially released on May 9, 2022. It was updated on May 25, 2022 to 

provide guidance on a required Privacy Notice and Privacy Act Statement, make technical corrections to Tables 1, 3,

and 7, clarify that Social Security numbers should not be reported as business EINs, provide a Sample Form for 

Demographics-Related Data, and reflect Paperwork Reduction Act approval. It was updated on September 30, 2022 

to add footnote 2 below. It was updated February 21, 2024 to clarify demographic reporting self certifications. 

2 To the extent that Treasury distributes templates or other materials to help carry out this Reporting Guidance, 

participating jurisdictions should follow the instructions included in those reporting materials.
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Each participating jurisdiction is responsible for the implementation of its SSBCI programs that 

have been approved by Treasury (“approved programs”) in accordance with applicable legal, 

regulatory, and program requirements, including those in the SSBCI statute and Treasury’s 

SSBCI regulations and guidance. Each participating jurisdiction must submit a certification, 

using the form in Appendix 1, with every quarterly or annual report, certifying that the 

information reported is accurate and that the approved programs of the participating jurisdiction 

are being implemented in accordance with applicable legal, regulatory, and compliance 

requirements.

Section II. Reporting Deadlines

a. Quarterly Reports

Each participating jurisdiction must submit to Treasury a quarterly report for the first full 

calendar quarter following the execution of its Allocation Agreement with Treasury and each 

quarter thereafter. Quarterly reports must be submitted within 30 days after the end of each 

quarterly reporting period (excluding the quarterly reporting period ending on the expiration date 

of the Allocation Agreement). Table 1 provides the submission deadlines for the specified 

reporting periods. The requirement to submit quarterly reports will terminate on the first March 

31 to occur after five complete 12-month periods after the jurisdiction is approved by Treasury to 

be a participating jurisdiction. Under current law, the last quarterly report is due January 30, 

2028; however, if the reporting requirement is extended by a future federal statute, then the 

extended expiration date shall automatically apply without further action by Treasury.

Table 1. Quarterly Report Deadlines

Reporting Period Submission Deadline

July 1, 2022 to September 30, 2022 October 30, 2022

October 1, 2022 to December 31, 2023 January 30, 2023

January 1, 2023 to March 31, 2023 April 30, 2023

April 1, 2023 to June 30, 2023 July 30, 2023

July 1, 2023 to September 30, 2023 October 30, 2023

October 1, 2023 to December 31, 2023 January 30, 2024

January 1, 2024 to March 31, 2024 April 30, 2024

April 1, 2024 to June 30, 2024 July 30, 2024

July 1, 2024 to September 30, 2024 October 30, 2024

October 1, 2024 to December 31, 2024 January 30, 2025

January 1, 2025 to March 31, 2025 April 30, 2025

April 1, 2025 to June 30, 2025 July 30, 2025

July 1, 2025 to September 30, 2025 October 30, 2025

October 1, 2025 to December 31, 2025 January 30, 2026

January 1, 2026 to March 31, 2026 April 30, 2026

April 1, 2026 to June 30, 2026 July 30, 2026

July 1, 2026 to September 30, 2026 October 30, 2026

October 1, 2026 to December 31, 2026 January 30, 2027
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Reporting Period Submission Deadline

January 1, 2027 to March 31, 2027 April 30, 2027

April 1, 2027 to June 30, 2027 July 30, 2027

July 1, 2027 to September 30, 2027 October 30, 2027

October 1, 2027 to December 31, 2027 January 30, 2028

b. Annual Reports

Starting in 2023, each participating jurisdiction must submit to Treasury an annual report for 

each calendar year by March 31 of the following year. Table 2 provides the submission deadlines 

for the specified reporting periods. The requirement to submit annual reports will terminate on 

the first March 31 to occur after five complete 12-month periods after the jurisdiction is 

approved by Treasury to be a participating jurisdiction. If the reporting requirement is extended 

beyond the initial expiration date by a future federal statute, then the extended expiration date 

shall automatically apply without further action by Treasury.

Table 2. Annual Report Deadlines

Reporting Period Submission Deadline

January 1, 2022 to December 31, 2022 March 31, 2023

January 1, 2023 to December 31, 2023 March 31, 2024

January 1, 2024 to December 31, 2024 March 31, 2025

January 1, 2025 to December 31, 2025 March 31, 2026

January 1, 2026 to December 31, 2026 March 31, 2027

January 1, 2027 to December 31, 2027 March 31, 2028

Section III. Definitions

The following definitions apply in this Reporting Guidance.

Administrative costs. As discussed in Section XI of the SSBCI Capital Program Policy 

Guidelines,3 SSBCI administrative costs are defined and governed by the Cost Principles of the 

OMB Administrative Requirements, Cost Principles, and Audit Requirements for Federal 

Awards (see Subpart E of 2 C.F.R. Part 200). The Cost Principles contain criteria that must be 

used to establish chargeable administrative costs and specific information on allowable costs in 

various cost categories. Pursuant to 2 C.F.R. § 200.405, administrative costs may be direct or 

indirect.

Allocated funds. All the federal funds that are awarded to the participating jurisdiction pursuant 

to 12 U.S.C. § 5702. 

Contracted entity. An entity that has a contractual arrangement (including through a 

memorandum of understanding or other agreement) with the participating jurisdiction or the 

participating jurisdiction’s implementing entity for the implementation or administration of its 

3 Available at https://home.treasury.gov/system/files/256/SSBCI-Capital-Program-Policy-Guidelines-November2021.pdf.
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capital program. This entity may be an authorized agent of the participating jurisdiction 

(including an entity or agency of the participating jurisdiction), or an entity selected and 

supervised by the participating jurisdiction (including an entity of another jurisdiction, a 

nonprofit third-party, or a for-profit third-party such as an investment fund or loan fund). The 

contracted entity may be the entity that operates the SSBCI program.

Controlling influence over a business. Having the power to control, manage, or direct the 

business. A person is presumed to have a controlling influence over a business if the person is a

senior executive officer or senior manager of the business (e.g., Chief Executive Officer, Chief 

Financial Officer, Chief Operating Officer), or any other individual who regularly performs 

similar functions.

Costs of program services. This is the costs of the services provided to a business that are

discussed in Section VIII.i of the Capital Program Policy Guidelines under “Services to Portfolio 

Companies.”

Expended, obligated, or transferred. Funds are considered “expended” if the expenses have 

been paid by, or are for, an approved state program. Examples of expended funds include: 

SSBCI funds that have been disbursed to a lender to cover the federal contribution to a CAP 

reserve fund; SSBCI funds that have been disbursed to a specific borrower (or disbursed to a 

specific lender as part of a commitment to a specific transaction) as part of a loan participation, 

collateral support, or direct lending program; SSBCI funds that have been invested in specific 

small businesses pursuant to a venture capital investment; and SSBCI funds that have been spent 

for allowable administrative expenses. Funds are considered “obligated” if they have been 

committed in writing to pay for the amounts of orders placed, contracts awarded, goods and 

services received, and similar transactions during a given period that will require payment by the 

approved state program during the same or a future period. Examples of obligated funds include: 

SSBCI funds that have been committed, pledged, or otherwise promised, in writing, to a specific 

borrower as part of a loan participation, collateral support, or direct lending program; SSBCI 

funds that have been set aside to cover obligations arising from loan guarantees; SSBCI funds 

that have been committed, pledged, or otherwise promised, in writing, as part of a venture capital 

investment transaction; and SSBCI funds that have been committed, pledged, or promised, in 

writing, for allowable administrative expenses (e.g., an executed contract for services). Funds are 

considered “transferred” if they have been transferred by the state receiving SSBCI funds to the 

implementing entity, or the contracted entity, that is charged with administering the day-to-day 

operations of the SSBCI program, as a reimbursement for actual expenses or when there is a 

clearly documented actual and immediate cash need to fund a loan or investment to an eligible 

small business or to pay for allowable administrative expenses. 

Financial institution. Any insured depository institution, insured credit union, or community 

development financial institution, as those terms are defined in section 103 of the Riegle 

Community Development and Regulatory Improvement Act of 1994 (12 U.S.C. § 4702).

Implementing entity. The specific department, agency, or political subdivision of the 

participating jurisdiction that has been designated to accept the SSBCI allocation on behalf of the 

participating jurisdiction. The term “agency” includes government corporations and other entities 
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authorized or supervised by the participating jurisdiction. The implementing entity may be the 

entity that operates the SSBCI program.

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.

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.

Program income. This is gross income received by the participating jurisdiction that is directly 

generated by an SSBCI-supported activity or earned as a result of an SSBCI allocation during the 

SSBCI program period. Program income includes, but is not limited to, income from: fees for 

services performed that were funded or supported with SSBCI funds, interest earned on loans 

made using SSBCI funds, interest on SSBCI funds not invested or lent to a business, and returns 

on SSBCI-supported equity investments. Program income does not include repayment of 

principal or return of invested capital.

Provider. The entity that transacts directly with the business by making a loan or investment 

supported by an approved SSBCI program. For loan programs (e.g., loan participation, loan 

guarantee, and collateral support programs; CAPS; and programs involving other credit support),

the provider is the lender whose loan is supported by SSBCI funds. For fund investment 

programs, the provider is the fund that invests SSBCI funds and private capital in a business. For 

direct investment programs, the provider is the implementing entity or contracted entity that 

invests SSBCI funds in a business.

Recycled funds. Funds that (1) come to the participating jurisdiction in the form of program 

income, returned program services costs, repayment of principal, or return of invested capital 

(i.e., funds that have been previously loaned or invested), and (2) are expended, obligated, or 

transferred by the participating jurisdiction on new loans, investments, or other credit equity 

support.

SEDI demographics-related business. A business 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 their (1) membership of a group that has 
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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.” 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 the 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. For purposes of this definition, 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) 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.

SSBCI funds. The sum of allocated funds and recycled funds.

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 IV. Quarterly Reporting

As described below, participating jurisdictions must provide two categories of information in the 

quarterly reports: (1) basic program information and (2) program-level information on the use of 

SSBCI funds.
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a. Basic Program Information in Quarterly Reports

For each of the participating jurisdiction’s approved SSBCI programs, the participating 

jurisdiction must provide the information listed in Table 3.

Table 3. Basic Program Information in Quarterly Reports

Data Element Description

Approved Program Name Confirm the name of each approved program. 

Program Type Confirm the program type of each approved program, as one of the 

following: 

-Credit – Loan participation program

-Credit – Loan guarantee program

-Credit – Collateral support program

-Credit – Capital access program

-Credit – Debt fund investment program

-Credit – Other support program 

-Equity – Fund investment program

-Equity – Direct investment program

-Equity – Other support program

-Hybrid – Other support program

Primary Program 

Administrator

Confirm the name of the entity primarily responsible for 

administering each approved program. 

b. Program-Level Information on the Use of SSBCI Funds in Quarterly Reports

For each of the participating jurisdiction’s approved SSBCI programs, the participating 

jurisdiction must provide the information listed in Table 4. The participating jurisdiction should 

provide additional descriptions as needed to help Treasury understand the reported information.

Table 4. Program-Level Information on the Use of SSBCI Funds in Quarterly Reports

Data Element Description

Approved Program Name Select the name of each approved program. 

Program Total Allocated 

Funds Expended, Obligated, 

or Transferred (EOT) 

Dollar amount of allocated funds EOT.

Program Allocated Funds 

EOT for Direct 

Administrative Costs 

Dollar amount of allocated funds EOT for direct administrative 

costs.

Program Allocated Funds 

EOT for Indirect 

Administrative Costs 

Dollar amount of allocated funds EOT for indirect administrative 

costs.
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Data Element Description

Program Total Recycled 

Funds EOT

Dollar amount of recycled funds EOT.

Contracted Entity Funding Dollar amount of SSBCI funds budgeted by 

the participating jurisdiction to each contracted entity.

Program Income Dollar amount of program income earned.

CAP Charge-offs

This field only appears if the 

program is a CAP.

Dollar amount of SSBCI funds used for charge-offs against federal 

contributions to CAP reserve funds.

Additional Information Text field for any additional clarifications, descriptions, or 

information.

Section V. Annual Reporting

Participating jurisdictions must provide various categories of information in annual reports. 

Table 5 indicates the frequency of reporting for each category.

Table 5. Annual Report Information and Frequency

Category of Information Reporting Frequency

Providers in an approved 

program (see Table 6 below)

Data only must be reported one time for each provider (unless 

there are updates to previously reported information), except that

allocated funds expended for costs of program services must be

reported on an annual basis.

Transactions (see Table 7

below)

Data must be reported only one time for each SSBCI-supported 

loan or investment.

Transaction terms (see 

Tables 8 and 9 below)

Data must be reported only one time for each SSBCI-supported 

loan or investment.

Loan or investment

performance (see Table 10

below)

Data must be reported annually for each SSBCI-supported loan 

or investment, if applicable.

Borrower/Investee Data (see 

Table 11 below)

Data should be reported annually after the closing of each SSBCIsupported loan or investment, if available.

In addition, each participating jurisdiction must provide a concise narrative for each approved 

program containing program-level updates on the progress the participating jurisdiction made on 

the plan it submitted with its SSBCI application on how the participating jurisdiction would use 

the federal contribution to the approved program to help provide access to capital for small 

businesses in underserved communities.4 The participating jurisdiction must also include any 

updates regarding the anticipated benefits to the jurisdiction from the approved program that 

were previously described in its application.5 Finally, the participating jurisdiction must provide 

4 For more information on this requirement, see Section IX.a of the Capital Program Policy Guidelines.

5 For more information on this requirement, see Section VIII.g of the Capital Program Policy Guidelines.
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an annual update of how the participating jurisdiction intends to apportion its allocation among 

its approved programs. 

a. Information about Providers in an Approved Program

Table 6 lists the data elements that the participating jurisdiction must report for each 

provider in an approved program. All data elements in Table 6, except for allocated funds

expended for costs of program services (the last item listed in Table 6), only need to 

be reported once and then updated in subsequent annual reports only if there are changes.

Table 6. Data Elements for Each Provider in an Approved Program6

Data Element Description

Approved Program Name Select the name of each approved program.

Provider Enter the name of the provider.

Provider EIN Provider’s employer identification number (EIN) or tax ID 

number. 

6 Note that an entity that is a provider may participate in more than one program of a participating jurisdiction or in 

programs of two or more participating jurisdictions. Examples might include lenders that participate both in a 

jurisdiction’s loan participation program and the jurisdiction’s loan guarantee program, or a venture capital fund that 

participates in programs of two different jurisdictions. In these cases, the entity (in these examples, the lender or 

venture capital fund) would have multiple provider records, one for each approved program of a participating 

jurisdiction that the entity serves as a provider.
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Data Element Description

Provider Regulatory ID For providers whose deposits are insured by the Federal Deposit 

Insurance Corporation (FDIC), provide the provider’s RSSD ID. 

For federally insured credit unions, provide the provider’s charter 

number from the National Credit Union Administration (NCUA). 

For Community Development Financial Institutions (CDFIs), 

provide the provider’s CDFI certification number. 

For fund managers registered as investment advisers with the 

Securities and Exchange Commission (SEC), provide the 

provider’s SEC registration number. 

For fund managers registered with the jurisdiction itself, 

provide the provider’s registration number from the jurisdiction. 

If none of the above regulatory IDs apply, but another regulatory 

ID applies, respond “Other.”

If no regulatory ID number applies, respond “None.”

If a provider has multiple regulatory IDs, the participating 

jurisdiction must provide at least one of these regulatory IDs and 

may provide additional regulatory IDs. 

Other Provider ID Text field for a description if the participating jurisdiction 

responded “Other” for the data element “Provider Regulatory ID.”
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Data Element Description

Provider Type Indicate what type of entity the provider is (if multiple types apply, 

choose the one that best describes the provider’s role in the 

program):

-CDFI bank, thrift, credit union, 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

-Accelerator or incubator 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 

Other Provider Type Text field for a description if the participating jurisdiction 

responded “Other” for the data element “Provider Type.”

Minority Depository 

Institution

Indicate whether the provider is a Minority Depository Institution.

-Yes

-No

Fund as Source of Private 

Capital 

Indicate whether the provider is a fund that is the primary source 

of private capital for the purpose of meeting the 1:1 financing 

requirement as described in Section VIII.c of the Capital Program 

Policy Guidelines. 

-Yes

-No

Provider as Source of Private 

Capital

If the provider is not a fund, indicate whether the provider is the 

primary source of private capital for the purpose of meeting the 1:1 

financing requirement as described in Section VIII.c of the Capital 

Program Policy Guidelines. 

-Yes

-No 

Target Fund Size If the provider is a fund, provide the target total fund 

size including SSBCI funds and other capital.
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Data Element Description

Incubation and Early-Stage

Investment Call Option

If the provider is an equity program, indicate whether a call option 

is offered under the Incubation or Early-Stage Investment Model 

described in Section VIII.i of the Capital Program Policy 

Guidelines. 

-Yes

-No

Allocated Funds Expended 

for Costs of Program 

Services

If the provider is a venture capital fund, specify the annual dollar 

amount of allocated funds expended by the fund for services to 

portfolio companies. This data element is reported on an annual 

basis.

b. SSBCI-Supported Loan and Investment Information

Table 7 lists the data elements that the participating jurisdiction must report for each SSBCIsupported loan or investment. Table 7 includes, among other items, demographics-related

information satisfying the requirements in the SSBCI Interim Final Rule.7 Tables 8 and 9 list 

data elements on transaction terms for credit programs and equity programs, respectively.

Each participating jurisdiction must report the data elements in Table 7 and in either Table 8 or 9 

for each SSBCI-supported loan or investment that received a disbursement from the provider to 

the business during the applicable annual reporting period. All data elements in Tables 7, 8, and 

9 only need to be reported once. Participating jurisdictions must provide a Privacy Notice and 

Privacy Act Statement (see Appendix 2) to those from whom they collect data, or cause the 

entities that collect this data directly to do the same.

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

SSBCI program and must not be used for any other purposes (e.g., marketing, sale to thirdparties). 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 Section 

IX.b of the Capital Program Policy Guidelines (Compliance with Civil Rights Requirements). 

Participating jurisdictions must establish processes to inform small businesses of this limited 

usage when these data elements are collected. Each participating jurisdiction shall establish data 

privacy and security requirements for the demographic-related information described in Table 7 

that include appropriate measures to ensure that the privacy of the individuals is 

protected. SSBCI is providing 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 (see 

Appendix 3). This sample form will be a useful tool for participating jurisdictions.

Table 7. SSBCI-Supported Loan and Investment Information for All Programs

Data Element Definition

Provider Select name of the provider.

7 State Small Business Credit Initiative; Demographics-Related Reporting Requirements, Department of the 

Treasury, 87 Federal Register 13628 (March 10, 2022).
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Data Element Definition

Approved Program Name Select the name of the approved program.

Unique Transaction ID Alphanumeric or numeric code that is unique to each transaction.

Business Name Name of the borrower or investee.

Business EIN EIN of the borrower or investee.

Do not provide a business EIN if it is a Social Security number.

Business Street Address Street address of the borrower or investee’s main office or location 

of the borrower or investee that is primarily benefitting from the 

SSBCI funds. If real estate construction financing is 

involved, enter the street address of the project.

Business City City of the borrower or investee.

Business State State of the borrower or investee.

Business Zip Code Zip code of the borrower or investee.

NAICS Code 2017 North American Industry Classification System (NAICS) 

codes for the borrower’s or investee’s industry.

Year Business Opened Year in which the borrower or investee commenced operations.

Form of Business

Organization

Legal entity type of the borrower or investee:

-Any organizational form that is a nonprofit entity

-Sole proprietor/independent contractor

-Partnership

-Limited liability company

-Corporation

-Worker cooperative or other employee-owned entity

-Tribal enterprise

-Tribal member-owned business

-Other

Other Type of Business 

Receiving SSBCI Funds

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

“Form of Business Organization.”

Tribal Government Program 

Transaction Type

This field only appears if the 

participating jurisdiction is a 

Tribal government.

Type of Tribal government program transaction. Select all that 

apply:

-In-jurisdiction transaction with business on Tribal lands

-In-jurisdiction transaction with business in states where the Tribe 

is physically located or within which the Tribe exercises 

jurisdiction 

-In-jurisdiction transaction with Tribal enterprise-operated 

business, business owned by Tribal members, or business in a state 

in which Tribal members reside

-Out-of-jurisdiction transaction – Transaction that does not fit into 

any of the categories above
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Data Element Definition

Primary Transaction Source 

of Private Capital

This field only appears if

response was “No” to both 

data element “Fund as

Source of Private Capital”

and to “Provider as Source of 

Private Capital” in Table 6.

Indicate the primary source of private capital to the business for 

the purpose of meeting the 1:1 financing requirement as described 

in Section VIII.c of the Capital Program Policy Guidelines:

-CDFI bank, thrift, credit union, 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

-Accelerator or incubator fund

-For-profit venture capital fund

-Nonprofit venture capital fund or venture/entrepreneurial 

development organization

-Corporate venture capital fund

-CDFI venture capital fund

-Tribal enterprise new funds

-Other for-profit investor

-Other non-profit investor
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Data Element Definition

Secondary Transaction 

Source of Private Capital

This field only appears if

response was “No” to both 

“Fund as Source of Private 

Capital” and to “Provider as

Source of Private Capital.”

Indicate the secondary sources of private capital to the business for 

the purpose of meeting the 1:1 financing requirement as described 

in Section VIII.c of the Capital Program Policy Guidelines. Select 

all that apply:

-CDFI bank, thrift, credit union, or depository institution holding 

company

-Community bank

-Non-CDFI 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 

-Accelerator or incubator fund

-For-profit venture capital fund

-Nonprofit venture capital fund or venture/entrepreneurial 

development organization

-Corporate venture capital fund

-CDFI venture capital fund

-Tribal enterprise new funds

-Other for-profit investor

-Other non-profit investor
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Data Element Definition

Primary Purpose of the Loan 

or Investment

Indicate the primary purpose of the SSBCI-supported loan or 

investment that the borrower or investee obtained: 

-Marketing, market research, and commercialization expenses

-Research and development 

-Technology integration in physical production, e.g., 

manufacturing or supply chain

-Technology integration of nonphysical production, e.g., 

accounting, customers

-Acquire land 

-Purchase existing building 

-Convert, expand, or renovate buildings – energy efficiency

-Convert, expand, or renovate buildings – other

-Construct new buildings

-Acquire and install fixed assets

-Acquire inventory

-Purchase supplies and raw materials

-Leasehold improvements

-Working capital – wages, salaries, and benefits of employees

-Working capital – other 

-Refinance outstanding debt

-Support employee stock ownership plan (ESOP) transactions

-Other

Purpose of the Loan or 

Investment – Other

Text field for description if selected “Other” in the data element

“Primary Purpose of the Loan or Investment.”
17

Data Element Definition

Secondary Purpose of the 

Loan or Investment

Indicate the secondary purpose of the SSBCI-supported loan or 

investment that the borrower or investee obtained. Select all that 

apply:

-Marketing, market research, and commercialization expenses

-Research and development 

-Technology integration in physical production, e.g., 

manufacturing or supply chain

-Technology integration of nonphysical production, e.g., 

accounting, customers

-Acquire land

-Purchase existing building

-Convert, expand, or renovate buildings – energy efficiency

-Convert, expand, or renovate buildings – other

-Construct new buildings

-Acquire and install fixed assets

-Acquire inventory

-Purchase supplies and raw materials

-Leasehold improvements

-Working capital – wages, salaries, and benefits of employees

-Working capital – other

-Refinance outstanding debt

-Support employee stock ownership plan (ESOP) transactions

-Other

Secondary Purpose of the 

Loan or Investment – Other

Text field for description if selected “Other” in the data element

“Secondary Purpose of the Loan or Investment.”

Climate-aligned Investment Indicate whether the SSBCI-supported loan or investment supports

a business that makes climate-aligned investments. Climatealigned investments may reduce greenhouse gas emissions or 

promote adaptation to climate change or energy transitions. This 

could be either in the business’s activities (including its production 

processes and use of energy, inputs, supply chain services, and/or 

actions to increase resiliency) or by supplying products and 

services that contribute to lower emissions. Climate-aligned 

investments can include investment supporting weatherization; 

energy-efficient prefabrication or manufacturing; supply chain use, 

processes or production resulting in lower emissions; energy site 

transitions; sustainable and/or climate-smart agriculture and 

forestry; renewable energy development or implementation 

(including wind, solar, hydroelectric, biomass, geothermal, and 

other low-carbon technologies); electric vehicle innovation or use; 

and other investments that aim to build climate resilience, support 

adaptation to extreme weather and climate events, and/or mitigate 

climate change.

-Yes

-No
18

Data Element Definition

Energy- or Climate-Impacted 

Communities

Indicate whether the SSBCI-supported loan or investment 

supports a small business in a community facing local job losses or 

business revenue declines due to physical or transition impacts 

from climate change, including shifts in energy production. 

Examples of such local job loss or revenue declines include 

declines due to changes in the economics of producing certain 

agriculture or foods, other natural resource goods, chemical inputs, 

manufactured products, or service sector outputs due to acute or 

chronic climate impacts, costs, regulations, or shifts in demand. 

Examples of shifts in energy production include any transition 

away from fossil fuel extraction, refining, or fossil-based energy 

generation in the oil, gas, and/or coal sector. 

-Yes

-No

Disbursement Date Date that the funds for the SSBCI-supported loan or 

investment were disbursed from the provider to the borrower or 

investee.

Loan or Investment 

Transaction Amount

Dollar amount that was disbursed from the provider to the business 

for the SSBCI-supported loan or investment, including SSBCI 

funds and private capital. 

Do not include any amounts reported under “Concurrent Private 

Financing” that are associated with, but separate from, the SSBCIsupported loan or investment.

Allocated Funds Expended

or Set Aside for Guarantees 

or Collateral Support 

Obligations 

For loan participation programs, dollar amount of allocated funds 

expended for the approved program’s participation in the loan. 

For loan guarantee programs, dollar amount of allocated funds set 

aside to cover the guarantee amount of commitment. 

For collateral support programs, dollar amount of allocated funds 

set aside to cover the collateral support obligation. 

For CAPs, dollar amount of allocated funds expended as the 

approved program’s contribution to the CAP reserve fund. 

For direct investment programs, dollar amount of allocated funds 

invested directly in a business. 

For fund investment programs, dollar amount of allocated funds 

invested directly in a business through a fund in which the 

participating jurisdiction has invested allocated funds.
19

Data Element Definition

Recycled Funds Expended or 

Set Aside for Guarantees or 

Collateral Support 

Obligations

For loan participation programs, dollar amount of recycled funds 

expended for the approved program’s participation in the loan. 

For loan guarantee programs, dollar amount of recycled funds set 

aside to cover the guarantee amount of commitment. 

For collateral support programs, dollar amount of recycled funds 

set aside to cover the collateral support obligation. 

For CAPs, dollar amount of recycled funds expended as the 

approved program’s contribution to the CAP reserve fund. 

For direct investment programs, dollar amount of recycled funds 

invested directly in a business.

For fund investment programs, dollar amount of recycled funds 

invested directly in a business through a fund in which the 

participating jurisdiction has invested recycled funds.

Additional Government 

Funds

Dollar amount of other funding from other public or government 

sources invested at the same time as the SSBCI-supported loan or 

investment.

Concurrent Private FinancingDollar amount of any private financing that was caused by or 

resulted from the SSBCI-supported loan or investment and that 

occurred at or around the same time as the SSBCIsupported loan or investment.

Business Revenue Borrower’s or investee’s annual gross revenues for the fiscal or 

calendar year prior to the closing of the loan or investment. This 

may be the most recent year for which taxes were filed.

Business Net Income Borrower’s or investee’s net income for the fiscal or calendar year 

prior to the closing of the loan or investment. This may be the 

most recent year for which taxes were filed.

Full-Time Equivalent

Employees

Borrower’s or investee’s full-time equivalent employees (FTEs), 

rounded to the nearest whole number, at the time of the closing of 

the SSBCI-supported loan or investment. This is determined by 

adding the number of full-time employees and 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.
20

Data Element Definition

Expected Jobs Created Number of full-time, part-time, and temporary jobs expected to be 

created as a direct result of the SSBCI-supported loan or 

investment within two years from the date of the loan or 

investment closing.

Expected Jobs Retained Number of full-time, part-time, and temporary job losses averted 

as a direct result of the SSBCI-supported loan or investment (not 

including jobs that were not at risk of being lost).

Self-certified SEDI Owned 

and Controlled in CDFI

Investment Area

Indicate whether the borrower or investee certified that it is owned 

and controlled by individuals whose residences are in CDFI 

Investment Areas.

-Self-certified

-The business did not certify

Self-certified SEDI Future

Location in CDFI Investment 

Area

Indicate whether the borrower or investee certified that it will 

operate a future location in a CDFI Investment Area.

-Self-certified

-The business did not certify

SEDI Status by Business

Address in CDFI Investment 

Area

Indicate whether the borrower or investee is located in a CDFI 

Investment Area, as evidenced by the business address. 

-Yes

-No

Self-Certified SEDI

Demographics-Related 

Business Status

Indicate whether the business self-certified that it is a SEDI

demographics-related business. Select which one or more of the 

categories that apply:

-Self-certified due to membership of a group that has been 

subjected to racial or ethnic prejudice or cultural bias within 

American society 

-Self-certified due to gender 

-Self-certified due to veteran status 

-Self-certified due to limited English proficiency 

-Self-certified due to disability

-Self-certified due to long-term residence in an environment 

isolated from the mainstream of American society

-Self-certified due to membership of a Federally or staterecognized Indian Tribe

-Self-certified due to long-term residence in a rural community 

-Self-certified due to residence in a U.S. territory

-Self-certified due to residence in a community undergoing 

economic transitions (including communities impacted by the shift 

towards a net-zero economy or deindustrialization)

-Self-certified due to membership of an “underserved community” 

as defined in Executive Order 13985 (see the definition of “SEDIowned and controlled business in Section II above)

-Self-certified to diminished access to credit, as defined, with no 

subcategory indicated.

-The business did not certify
21

Data Element Definition

Minority-Owned or 

Controlled Business Status

Indicate whether the business 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 business 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 business is a veteran-owned or controlled 

business: 

-Yes

-No

-Prefer not to respond

-The business did not answer

Race of Principal Owners For each principal owner of the business, indicate the one or more 

race categories with which the principal owner identifies: 

-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

Ethnicity of Principal 

Owners

For each principal owner of the business, indicate which of the 

following ethnicity categories the principal owner identifies with: 

-Hispanic or Latino/a 

-Not Hispanic or Latino/a

-Prefer not to respond

-The business did not answer
22

Data Element Definition

Middle Eastern or North 

African Ancestry of Principal 

Owners

For each principal owner of the business, indicate which of the 

following ancestry categories the principal owner identifies with: 

-Middle Eastern or North African 

-Not Middle Eastern or North African

-Prefer not to respond

-The business did not answer

Gender of Principal Owners For each principal owner of the business, indicate which one of the 

following gender categories the principal owner identifies with: 

-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 Principal Owners.”

Sexual Orientation of 

Principal Owners

For each principal owner of the business, indicate which one of the 

following sexual orientation categories the principal owner 

identifies with: 

-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

For each principal owner of the business, indicate which of the 

following categories the principal owner identifies with: 

-Veteran

-Non-veteran

-Prefer not to respond

-The business did not answer

Table 8. Transaction Terms Specific to Credit Programs

Data Element Definition

Unique Transaction ID Alphanumeric or numeric code that is unique to each transaction.

Loan Type Type of loan:

-Term with a specified repayment schedule and a fixed or floating 

interest rate

-Revenue-based, income-based, or other performance-contingent 

payments

-Line of credit

-Bridge, venture debt or other debt whose repayment is contingent 

on event (with or without interim interest payments)

-Other
23

Data Element Definition

Other Loan Type Text field for description if selected “Other” in the data 

element “Loan Type.”

Loan Term Duration of the loan term in months.

Provide an estimate if repayment depends on the borrower’s 

revenue or performance activity.

Loan APR Annual percentage rate (APR) charged to the borrower. The APR 

is the yearly interest calculated from a sum that's charged to 

borrowers, including fees.

Interest Rate Variability Variability of interest rate:

-Fixed interest rate

-Adjustable interest rate

-Both a fixed interest rate and an adjustable interest rate 

Other Repayment Terms Text field for description of material terms (e.g., percentage of 

monthly revenues) if the loan is revenue-based or performancebased.

Maximum Interest Rate Maximum interest rate permitted under the loan (not including 

fees, penalty interest, or other charges).

Total Origination Charges Total dollar amount of charges imposed directly or indirectly by 

the provider at or before origination as an incident to or a condition 

of the extension of credit, including charges paid by the borrower 

at or before origination or that are financed. Charges that are 

imposed indirectly by the provider include charges by a third party 

that may pass through the provider to the borrower or that are 

billed separately.

Table 9. Transaction Terms Specific to Equity Programs

Data Element Definition

Unique Transaction ID Alphanumeric or numeric code that is unique to each transaction.

Stage of Investment Stage of the business on the transaction date for all equity 

investments:

-Pre-Seed – developing technology or business model for 

product/service 

-Seed – proof-of-concept and developed business model 

-Early Stage – product/service launch and market traction

-Later Stage – scale-up operations and growing revenue

-Growth Equity – mature business seeking growth opportunities

-Other
24

Data Element Definition

Security Type Type of security purchased:

-Common stock

-Preferred stock

-Convertible debt (debt with automatic conversion to equity in a

qualified priced round)

-Standard agreement for future equity (SAFE) or other 

unpriced equity-like securities

-Other

Other Security Offered Text field for description if selected “Other” in the data 

element “Security Type.”

SSBCI Ownership Percentage

This field only appears if 

common stock or preferred 

stock.

For direct investment programs, the percentage of equity 

ownership of the business on a fully diluted basis acquired using 

SSBCI funds. 

For fund investment programs, the implied percent of equity 

ownership of the business on a fully diluted basis that is 

calculated, for example by multiplying the percent of the SSBCI 

funds investment in an equity fund times the percent of the 

business which the equity fund owns after the transaction, or by 

some other method.

The participating jurisdiction selects one:

-0% to 5%

-5% to 10%

-10% to 20%

-20% to 50%

-Greater than 50%

Conversion Discount

This field only appears 

if convertible note, SAFE or 

other unpriced equity-like

securities.

Percentage reduction on the price of equity shares at 

which the convertible note investors’ claim converts to 

equity relative to the next qualified priced round. 

Valuation Cap

This field only appears if 

convertible note, SAFE or 

other unpriced equity-like

securities.

Imposed maximum valuation of the business used to price the 

SSBCI investment for conversion into equity shares at the next 

qualified priced round.

Type of Valuation Cap

This field only appears if 

convertible note, SAFE or 

other unpriced equity-like

securities.

Indicate whether the valuation cap is pre-money or post-money.

-Pre-money

-Post-money 
25

c. SSBCI-Supported Loan and Investment Performance Information

Table 10 lists additional data that each participating jurisdiction must report for each SSBCIsupported loan or investment. The data specified in Table 10 must be reported in the annual 

report, if applicable, for an SSBCI-supported loan or investment. The purpose of this information 

is to understand how the loan or investment performed and affected the business.

As shown in Table 10, subsequent private financing caused by, or resulting from, the initial 

SSBCI-supported OCSP financing must be reported. Subsequent financing is considered to be

caused by, or resulting from, the initial SSBCI-supported OCSP financing when such OCSP 

financing increases the current and future creditworthiness of a business. This nexus between the 

initial SSBCI-supported loan or investment and subsequent private financing occurs only when 

such loan or investment is a form of subordinated, mezzanine, or equity financing—in other 

words, a form of financing that strengthens the business’s balance sheet. If there is no such 

nexus, then no subsequent private financing is reported. 

Participating jurisdictions report subsequent private financing until (1) the completion of the 

contract, default or business failure, an exit event, or other event that ends the lending or 

investment relationship, or (2) the end of the SSBCI program reporting requirements.

Table 10. Information on SSBCI-Supported Loan or Investment Performance

Data Element Definition

Unique Transaction ID Alphanumeric or numeric code that is unique to each transaction.

Subsequent Private 

Financing

Total dollar amount of private financing received after closing of 

the loan or investment that is caused by, or resulting from, the 

initial SSBCI-supported loan or investment.

SSBCI Funds Lost Dollar amount of SSBCI funds that were lost (by the jurisdiction) 

due to loan default or loss of investment (i.e., an investment is 

written off).

Equity Investment Gains Dollar amount of any gains returned to the jurisdiction (as the 

SSBCI investor/lender) above the amount of invested SSBCI

capital.

Table 11 lists additional data that participating jurisdictions should collect from the borrower or 

investee annually after the closing of each SSBCI-supported loan or investment, if available. The 

data specified in Table 11 should be reported in each annual report, if available.

Table 11. Borrower/Investee Data

Data Element Definition

Business Revenue Borrower’s or investee’s annual gross revenues for its most recent

fiscal or calendar year. This may be the most recent year for which 

taxes were filed. There will be an option to report that the 

information is not available.
26

Data Element Definition

Business Net Income Borrower’s or investee’s net income for its most recent fiscal or 

calendar year. This may be the most recent year for which taxes 

were filed. There will be an option to report that the information is 

not available.

Year of Reported Business 

Revenue and/or Net Income 

Fiscal or calendar year of the data reported for Business Revenue 

and/or Business Net Income.

Section VI. Record Retention and Increase of Frequency and Scope of Reporting

Before providing funding to a private entity using SSBCI funds, each participating jurisdiction 

must obtain the following:

• The written agreement of the private entity, including any financial institution, to make 

available to the Treasury Inspector General and the Government Accountability Office all 

books and records related to the use of the SSBCI funds, subject to applicable privacy 

laws, including but not limited to 12 U.S.C. § 3401 et seq., including detailed loan and 

investment records, as applicable; 

• A certification from the private entity, if it is a financial institution, that the private entity

is in compliance with the requirements of 31 C.F.R. § 1020.220, regarding customer 

identification programs; and 

• A certification from the private entity, including any financial institution, that the 

principals of such entity have not been convicted of a sex offense against a minor (as 

such terms are defined in section 111 of the Sex Offender Registration and Notification 

Act (42 U.S.C. 16911)).

Treasury will apply record retention principles that are consistent with the approach set forth in 

2 C.F.R. § 200.334. Each participating jurisdiction must retain all financial records, supporting 

documents, statistical records, and all other records pertinent to its SSBCI allocation for a period 

of three years from the date of submission of the final quarterly report under Section II.a, except 

as otherwise provided in 2 C.F.R. § 200.334. Treasury, the Treasury Inspector General, the 

Government Accountability Office, or any of their duly authorized representatives have the right 

of timely and unrestricted access to any books, documents, papers, or other records of the 

participating jurisdiction that are pertinent to the participating jurisdiction’s allocation, in order 

to make audits, investigations, examinations, excerpts, transcripts, and copies of such documents. 

This right also includes timely and reasonable access to the participating jurisdiction’s personnel 

for the purpose of interviews and discussion related to such documents. This right of access will 

last as long as records are required to be retained, except that Treasury’s right of access expires 

on the date that is 180 days after the end of the period of performance for the participating 

jurisdiction’s SSBCI funds.

Treasury may unilaterally increase the frequency and the scope of a participating jurisdiction’s

reporting requirements if Treasury finds the participating jurisdiction to be a high-risk

jurisdiction. To determine whether a participating jurisdiction is a high-risk jurisdiction, 

Treasury will apply a risk evaluation approach that is consistent with the principles set forth in 

2 C.F.R. § 200.206. Treasury may find a participating jurisdiction to be a high-risk jurisdiction 
27

prior to the jurisdiction’s receipt of allocated funds or after the participating jurisdiction receives 

its allocated funds.

Because participating jurisdictions and their contracted entities will be receiving sensitive 

information, Treasury strongly encourages participating jurisdictions and their contracted entities 

to establish robust protections against data breaches and misuse and to comply with all 

applicable privacy laws.

Paperwork Reduction Act Notice - OMB Control Number 1505-0227

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. 
Appendix 1.

Certification Required with SSBCI Quarterly and Annual Reports

The undersigned, on behalf of the participating jurisdiction specified below, hereby makes the 

following certifications as of the date of this certification:

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

participating jurisdiction specified below to the U.S. Department of the Treasury related 

to the State Small Business Credit Initiative (SSBCI) are true and correct and do not 

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

omission of any material fact;

2. SSBCI funds continue to be available and legally committed to contributions by 

the participating jurisdiction to, or for the account of, approved programs, less any 

amount that has already been contributed by the participating jurisdiction to, or for the 

account of, approved programs subsequent to the participating jurisdiction being 

approved for participation in the SSBCI; 

3. The participating jurisdiction is implementing its approved SSBCI program or programs 

in accordance with all applicable legal, regulatory, and program requirements, 

including the SSBCI statute (12 U.S.C. § 5701 et seq.) and the U.S. Department of 

the Treasury’s SSBCI regulations and guidance to the best of the undersigned’s 

knowledge; and 

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

the participating jurisdiction.

IN WITNESS WHEREOF, this certificate has been duly executed and delivered as of 

the [ ] day of [ ], 202[ ]. 

[Name of Participating Jurisdiction]

By: _______________________________

Name:

Title:
Appendix 2.

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 has published a Privacy and Civil Liberties Impact Assessment that 

describes what Treasury will do with the information your business provides in this application. 

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 federal law, 

including 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 and to advance fairness 

and opportunity in underserved communities in the allocation of federal resources. 

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 and Compliance 

Review Files; Treasury .015, General Information Technology Access Account Records; and 

Treasury .017, Correspondence and Contact Information. 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 System of Records Notices (SORNs) listed above, which are posted on 

Treasury’s website.

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

information (except for the demographic information) may result in the denial of your 

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

information, it will not adversely affect your application.
Appendix 3.

SSBCI Sample Form for Demographics-Related Data

This sample form may be used by a participating jurisdiction and/or its providers to obtain 

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

participating jurisdictions. Participating jurisdictions may adopt their own form, provided that it 

complies with all SSBCI requirements.

Legal name of borrower or investee: __________________________________________

This transaction is supported with funding provided through the State Small Business Credit 

Initiative (SSBCI), a federal program that supports small business lending and investment 

programs in states, the District of Columbia, territories, and Tribal governments (collectively, 

“participating jurisdictions”). SSBCI programs are designed to expand access to capital, promote 

economic resiliency, and create new jobs and economic opportunity. 

Filling out this form and providing demographic information is optional; applicants are not 

required to provide the requested information but are encouraged to do so. The entity collecting 

this information cannot discriminate on the basis of whether an applicant provides this 

information, or based on any information provided on this form. If you decline to provide this 

information, it will not adversely affect your application.

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

program and must not be used for any other purposes (e.g., marketing, sale to third parties). The 

information collected must also not be used in a manner that violates any applicable 

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 Diversity, 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 1505-0227

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.
Applicants are encouraged to answer all of the questions below.

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

are being fulfilled and allow SSBCI to analyze the populations that SSBCI 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 applicant 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 applicant 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 applicant a veteran-owned or controlled 

business?

☐ Yes ☐ No ☐ Prefer not to 

respond
Each principal owner of the applicant is encouraged to answer the questions below.

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

are being fulfilled and allow SSBCI to analyze the populations that SSBCI funding is benefiting.

For purposes of this form, a principal owner of the applicant 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.

For each principal owner of the applicant, indicate which of the following categories the

principal owner identifies with. Submit a separate copy of this table for each principal owner of 

the applicant (up to four).

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 

☐ 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

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