SBA Form 2483-SD (2/21) 1

( 

Paycheck Protection Program 

Second Draw Borrower Application Form Revised February 17, 2021 

OMB Control No.: 3245-0417

Expiration Date: 7/31/2021

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

 Independent contractor  Self-employed individual

 501(c)(3) nonprofit  501(c)(6) organization

 501(c)(19) veterans organization  Housing cooperative

 Tribal business  Other _ ___________________________

DBA or Tradename (if 

applicable)

Year of Establishment (if 

applicable)

Business Legal Name NAICS Code

Business Address (Street, City, State, Zip Code - No P.O. Box addresses 

allowed) Business TIN (EIN, SSN) Business Phone

Primary Contact Email Address

Average Monthly 

Payroll: $ $

x 2.5 (or x 3.5 for NAICS 

72 applicants) equals Loan 

Request Amount (may not 

exceed $2,000,000):

Number of Employees

(including affiliates, if 

applicable; may not exceed 300): 

Purpose of the 

loan (select all that 

apply): 

☐Payroll Costs ☐Rent / Mortgage Interest ☐Utilities ☐Covered Operations

Expenditures

☐Covered Property

Damage

☐Covered Supplier Costs ☐Covered Worker

Protection Expenditures

☐Other (explain):

______________________

PPP First Draw 

SBA Loan Number:

Reduction in Gross Receipts of at Least 

25% (Applicants for loans of $150,000 or 

less may leave blank but must provide 

upon or before seeking loan forgiveness

or upon SBA request):

2020 Quarter

(e.g., 2Q 2020): 

Gross Receipts: $

Reference Quarter 

(e.g., 2Q 2019):

Gross Receipts $

Applicant Ownership

List all owners of 20% or more of the equity of the Applicant. Attach a separate sheet if necessary.

Owner Name Title Ownership % TIN (EIN, SSN) Address

PPP Borrower Demographic Information (Optional)

Veteran/gender/race/ethnicity data is collected for program reporting purposes only. Disclosure is voluntary and will have no bearing on the 

loan application decision. 

Principal Name Position 

Select Response Below:

Veteran ☐ Non-Veteran; ☐ Veteran; ☐ Service-Disabled Veteran; ☐ Spouse of Veteran; ☐ Not Disclosed

Gender ☐ Male; ☐ Female; ☐ Not Disclosed

Race (more than 1 may 

be selected)

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

☐ Native Hawaiian or Pacific Islander; ☐ White; ☐ Not Disclosed

Ethnicity ☐ Hispanic or Latino; ☐ Not Hispanic or Latino; ☐ Not Disclosed
 

 

 

 

 

 

 

Paycheck Protection Program 

Second Draw Borrower Application Form Revised February 17, 2021 

If questions (1), (2), (4), or (5) are answered “Yes,” the loan will not be approved. 

Question Yes No 

1. Is the Applicant or any owner of the Applicant presently suspended, debarred, proposed for debarment, declared ineligible,

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

bankruptcy?

2. Has the Applicant, any owner of the Applicant, or any business owned or controlled by any of them, ever obtained a direct or

guaranteed loan from SBA or any other Federal agency that is (a) currently delinquent, or (b) has defaulted in the last 7 years and

caused a loss to the government?

3. Is the Applicant or any owner of the Applicant an owner of any other business, or have common management (including a

management agreement) with any other business? If yes, list all such businesses (including their TINs if available) and describe the

relationship on a separate sheet identified as addendumA.

4. Is the Applicant (if an individual) or any individual owning 20% or more of the equity of the Applicant presently incarcerated or, for

any felony, presently subject to an indictment, criminal information, arraignment, or other means by which formal criminal charges

are brought in any jurisdiction?

Initial here to confirm your response to question 4 →

5. Within the last 5 years, for any felony involving fraud, bribery, embezzlement, or a false statement in a loan application or an

application for federal financial assistance, or within the last year, for any other felony, has the Applicant (if an individual) or any

owner of the Applicant 1) been convicted; 2) pleaded guilty; 3) pleaded nolo contendere; or 4) commenced any form of parole or

probation (including probation before judgment)?

Initial here to confirm your response to question 5 →

6. Is the United States the principal place of residence for all employees included in the Applicant’s payroll calculation above?

7. Is the Applicant a franchise?

8. Is the franchise listed in SBA’s Franchise Directory? If yes, enter SBA Franchise Identifier Code here: _______________

SBA Form 2483-SD (2/21) 2 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Paycheck Protection Program 

Second Draw Borrower Application Form Revised February 17, 2021 

By Signing Below, You Make the Following Representations, Authorizations, and Certifications 

I certify that: 

• I have read the statements included in this form, including the Statements Required by Law and Executive Orders, and I understand them.

• The Applicant is eligible to receive a loan under the rules in effect at the time this application is submitted that have been issued by the Small

Business Administration (SBA) and the Department of the Treasury (Treasury) implementing Second Draw Paycheck Protection Program Loans

under Division A, Title I of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) and the Economic Aid to Hard-Hit Small

Businesses, Nonprofits, and Venues Act (the Paycheck Protection Program Rules).

• The Applicant, together with its affiliates (if applicable), (1) is an independent contractor, self-employed individual, or sole proprietor with no

employees; (2) employs no more than 300 employees; or (3) if NAICS 72, employs no more than 300 employees per physical location; (4) if a

news organization that is majority owned or controlled by a NAICS code 511110 or 5151 business or a nonprofit public broadcasting entity with 

a trade or business under NAICS code 511110 or 5151, employs no more than 300 employees per location.

• I will comply, whenever applicable, with the civil rights and other limitations in this form.

• All loan proceeds will be used only for business-related purposes as specified in the loan application and consistent with the Paycheck Protection 

Program Rules including the prohibition on using loan proceeds for lobbying activities and expenditures. If Applicant is a news organization

that became eligible for a loan under Section 317 of the Economic Aid to Hard-Hit Small Businesses, Nonprofits, and Venues Act, proceeds of

the loan will be used to support expenses at the component of the business concern that produces or distributes locally focused or emergency

information.

• I understand that SBA encourages the purchase, to the extent feasible, of American-made equipment and products.

• The Applicant is not engaged in any activity that is illegal under federal, state or local law.

For Applicants who are individuals: I authorize the SBA to request criminal record information about me from criminal justice agencies for the 

purpose of determining my eligibility for programs authorized by the Small Business Act, as amended. 

The authorized representative of the Applicant must certify in good faith to all of the below by initialing next to each one: 

The Applicant was in operation on February 15, 2020, has not permanently closed, and was either an eligible self-employed individual, 

independent contractor, or sole proprietorship with no employees, or had employees for whom it paid salaries and payroll taxes or paid 

independent contractors, as reported on Form(s) 1099-MISC. 

Current economic uncertainty makes this loan request necessary to support the ongoing operations of the Applicant. 

The Applicant has realized a reduction in gross receipts in excess of 25% relative to the relevant comparison time period. For loans greater 

than $150,000, Applicant has provided documentation to the lender substantiating the decline in gross receipts. For loans of $150,000 or 

less, Applicant will provide documentation substantiating the decline in gross receipts upon or before seeking loan forgiveness for the Second 

Draw Paycheck Protection Program Loan or upon SBA request. 

The Applicant received a First Draw Paycheck Protection Program Loan and, before the Second Draw Paycheck Protection Program Loan 

is disbursed, will have used the full loan amount (including any increase) of the First Draw Paycheck Protection Program Loan only for 

eligible expenses. 

The funds will be used to retain workers and maintain payroll; or make payments for mortgage interest, rent, utilities, covered operations 

expenditures, covered property damage costs, covered supplier costs, and covered worker protection expenditures as specified under the 

Paycheck Protection Program Rules; I understand that if the funds are knowingly used for unauthorized purposes, the federal government 

may hold me legally liable, such as for charges of fraud. 

I understand that loan forgiveness will be provided for the sum of documented payroll costs, covered mortgage interest payments, covered 

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

protection expenditures, and not more than 40% of the forgiven amount may be for non-payroll costs. If required, the Applicant will provide 

to the Lender and/or SBA documentation verifying the number of full-time equivalent employees on the Applicant’s payroll as well as the 

dollar amounts of eligible expenses for the covered period following this loan. 

_____ The Applicant has not and will not receive another Second Draw Paycheck Protection Program Loan. 

The Applicant has not and will not receive a Shuttered Venue Operator grant from SBA. 

SBA Form 2483-SD (2/21) 3 
 

 

 

 

 

 

 

 

 

 

 

 

 

_________________________________________________________ ________________________ 

_________________________________________________________ ________________________ 

Paycheck Protection Program 

Second Draw Borrower Application Form Revised February 17, 2021 

The President, the Vice President, the head of an Executive department, or a Member of Congress, or the spouse of such person as determined 

under applicable common law, does not directly or indirectly hold a controlling interest in the Applicant, with such terms having the meanings 

provided in Section 322 of the Economic Aid to Hard-Hit Small Businesses, Nonprofits, and Venues Act. 

The Applicant is not an issuer, the securities of which are listed on an exchange registered as a national securities exchange under section 6 

of the Securities Exchange Act of 1934 (15 U.S.C. 78f). 

The Applicant is not a business concern or entity (a) for which an entity created in or organized under the laws of the People’s Republic of 

China or the Special Administrative Region of Hong Kong, or that has significant operations in the People’s Republic of China or the Special 

Administrative Region of Hong Kong, owns or holds, directly or indirectly, not less than 20 percent of the economic interest of the business 

concern or entity, including as equity shares or a capital or profit interest in a limited liability company or partnership; or (b) that retains, as 

a member of the board of directors of the business concern, a person who is a resident of the People’s Republic of China. 

The Applicant is not required to submit a registration statement under section 2 of the Foreign Agents Registration Act of 1938 (22 U.S.C. 

612). 

The Applicant is not a business concern or entity primarily engaged in political or lobbying activities, including any entity that is organized 

for research or for engaging in advocacy in areas such as public policy or political strategy or otherwise describes itself as a think tank in any 

public documents.

 I further certify that the information provided in this application and the information provided in all supporting documents and forms is true 

and accurate in all material respects. I understand that knowingly making a false statement to obtain a guaranteed loan from SBA is punishable 

under the law, including under 18 U.S.C. 1001 and 3571 by imprisonment of not more than five years and/or a fine of up to $250,000; under 

15 U.S.C. 645 by imprisonment of not more than two years and/or a fine of not more than $5,000; and, if submitted to a federally insured 

institution, under 18 U.S.C. 1014 by imprisonment of not more than thirty years and/or a fine of not more than $1,000,000. 

I acknowledge that the Lender will confirm the eligible loan amount using required documents submitted. I understand, acknowledge, and 

agree that the Lender can share any tax information that I have provided with SBA’s authorized representatives, including authorized 

representatives of the SBA Office of Inspector General, for the purpose of compliance with SBA Loan Program Requirements and all SBA 

reviews. 

Signature of Authorized Representative of Applicant Date 

Print Name Title 

SBA Form 2483-SD (2/21) 4 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Paycheck Protection Program 

Second Draw Borrower Application Form Revised February 17, 2021 

Purpose of this form: 

This form is to be completed by the authorized representative of the Applicant and submitted to your SBA Participating Lender. Submission of the requested 

information is required to make a determination regarding eligibility for financial assistance. Failure to submit the information would affect that 

determination. 

Instructions for completing this form: 

With respect to “purpose of the loan,” payroll costs consist of compensation to employees (whose principal place of residence is the United States) in the 

form of salary, wages, commissions, or similar compensation; cash tips or the equivalent (based on employer records of past tips or, in the absence of such 

records, a reasonable, good-faith employer estimate of such tips); payment for vacation, parental, family, medical, or sick leave (except those paid leave 

amounts for which a credit is allowed under FFCRA Sections 7001 and 7003); allowance for separation or dismissal; payment for the provision of employee 

benefits consisting of group health care coverage (including insurance premiums), group life, disability, vision, or dental insurance, and retirement benefits; 

payment of state and local taxes assessed on compensation of employees; and, for an independent contractor or sole proprietor, wage, commissions, income, 

or net earnings from self-employment or similar compensation. 

For purposes of calculating “Average Monthly Payroll,” most Applicants will use the average monthly payroll for 2019 or 2020, excluding costs over 

$100,000 on an annualized basis, as prorated for the period during which the payments are made or the obligation to make the payments is incurred, for 

each employee. For seasonal businesses, the Applicant may elect to instead use average total monthly payroll for any twelve-week period selected by the 

Applicant between February 15, 2019 and February 15, 2020, excluding costs over $100,000 on an annualized basis, as prorated for the period during which 

the payments are made or the obligation to make the payments is incurred, for each employee. For new businesses without 12 months of payroll costs but 

that were in operation on February 15, 2020, average monthly payroll may be calculated based on the number of months in which payroll costs were incurred, 

excluding costs over $100,000 on an annualized basis for each employee, as prorated for the period during which the payments are made or the obligation 

to make the payments is incurred, for each employee. For farmers and ranchers that operate as a sole proprietorship or as an independent contractor, or who 

are eligible self-employed individuals and report farm income or expenses on a Schedule F (or any equivalent successor IRS form), payroll costs are 

computed using eligible payroll costs for employees, if any, plus the lesser of $100,000 and the difference between gross income and any eligible payroll 

costs for employees, as reported on a Schedule F. For Applicants that file IRS Form 1040, Schedule C, payroll costs are computed using line 31 net profit 

amount, limited to $100,000, plus any eligible payroll costs for employees. For Applicants that are partnerships, payroll costs are computed using net 

earnings from self-employment of individual general partners, as reported on IRS Form 1065 K-1, reduced by section 179 expense deduction claimed, 

unreimbursed partnership expenses claimed, and depletion claimed on oil and gas properties, multiplied by 0.9235, that is not more than $100,000, plus any 

eligible payroll costs for employees. 

In determining whether the Applicant experienced at least a 25% reduction in gross receipts, for loans above $150,000, the Applicant must identify the 2020 

quarter meeting this requirement, identify the reference quarter, and state the gross receipts amounts for both quarters, as well as provide supporting 

documentation. For loans of $150,000 and below, these fields are not required and the Applicant only must certify that the Applicant has met the 25% gross 

receipts reduction at the time of application; however, upon or before seeking loan forgiveness (or upon SBA request) the Applicant must provide 

documentation that identifies the 2020 quarter meeting this requirement, identifies the reference quarter, states the gross receipts amounts for both quarters, 

and supports the amounts provided. For all loans, the appropriate reference quarter depends on how long the Applicant has been in operation: 

• For all entities other than those satisfying the conditions set forth below, Applicants must demonstrate that gross receipts in any quarter of 2020 were

at least 25% lower than the same quarter of 2019. Alternatively, Applicants may compare annual gross receipts in 2020 with annual gross receipts in

2019; Applicants choosing to use annual gross receipts must enter “Annual” in the 2020 Quarter and Reference Quarter fields and, as required

documentation, must submit copies of annual tax forms substantiating the annual gross receipts reduction.

• For entities not in business during the first and second quarters of 2019 but in operation during the third and fourth quarters of 2019, Applicants must

demonstrate that gross receipts in any quarter of 2020 were at least 25% lower than either the third or fourth quarters of 2019.

• For entities not in business during the first, second, and third quarters of 2019 but in operation during the fourth quarter of 2019, Applicants must

demonstrate that gross receipts in any quarter of 2020 were at least 25% lower than the fourth quarter of 2019.

• For entities not in business during 2019 but in operation on February 15, 2020, Applicants must demonstrate that gross receipts in the second, third, or

fourth quarter of 2020 were at least 25% lower than the first quarter of 2020.

Gross receipts includes all revenue in whatever form received or accrued (in accordance with the entity’s accounting method) from whatever source, 

including from the sales of products or services, interest, dividends, rents, royalties, fees, or commissions, reduced by returns and allowances. Generally, 

receipts are considered “total income” (or in the case of a sole proprietorship “gross income”) plus “cost of goods sold” and excludes net capital gains or 

losses as these terms are defined and reported on IRS tax return forms. Gross receipts do not include the following: taxes collected for and remitted to a 

taxing authority if included in gross or total income, such as sales or other taxes collected from customers and excluding taxes levied on the concern or its 

employees; proceeds from transactions between a concern and its domestic or foreign affiliates; and amounts collected for another by a travel agent, real 

estate agent, advertising agent, conference management service provider, freight forwarder or customs broker. All other items, such as subcontractor costs, 

reimbursements for purchases a contractor makes at a customer's request, investment income, and employee-based costs such as payroll taxes, may not be 

excluded from gross receipts. Gross receipts of a borrower must be aggregated with gross receipts of its affiliates. For a nonprofit organization, veterans 

organization, nonprofit news organization, 501(c)(6) organization, and destination marketing organization, gross receipts has the meaning in section 6033 

of the Internal Revenue Code of 1986. 

For purposes of reporting Number of Employees, sole proprietors, self-employed individuals, and independent contractors should include themselves as 

employees (i.e., the minimum number in the box “Employees” is one). For NAICS 72 or eligible news organizations, applicants may not exceed 300 per 

physical location. 

For purposes of reporting Year of Establishment, self-employed individuals and independent contractors may enter “NA”. 

For purposes of reporting NAICS Code, applicants must match the business activity code provided on their IRS income tax filings, if applicable. For 

purposes of calculating an Applicant’s maximum payroll costs, an Applicant may multiply its average monthly payroll costs by 3.5 only if the Applicant is 

in the Accommodation and Food Services sector and has reported a NAICS code beginning with 72 as its business activity code on its most recent IRS 

income tax return. 

SBA Form 2483-SD (2/21) 5 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Paycheck Protection Program 

Second Draw Borrower Application Form Revised February 17, 2021 

All parties listed below are considered owners of the Applicant: 

• For a sole proprietorship, the sole proprietor;

• For a partnership, all general partners, and all limited partners owning 20% or more of the equity of the firm;

• For a corporation, all owners of 20% or more of the corporation;

• For limited liability companies, all members owning 20% or more of the company; and

• Any Trustor (if the Applicant is owned by a trust).

For purposes of reporting (optional) demographic information: 

1. Purpose. Veteran/gender/race/ethnicity data is collected for program reporting purposes only.

2. Description. This form requests information about each of the Borrower’s Principals. Add additional sheets if necessary.

3. Definition of Principal. The term “Principal” means:

• For a self-employed individual, independent contractor, or a sole proprietor, the self-employed individual, independent contractor, or sole

proprietor.

• For a partnership, all general partners and all limited partners owning 20% or more of the equity of the Borrower, or any partner that is

involved in the management of the Borrower’s business.

• For a corporation, all owners of 20% or more of the Borrower, and each officer and director.

• For a limited liability company, all members owning 20% or more of the Borrower, and each officer and director.

• Any individual hired by the Borrower to manage the day-to-day operations of the Borrower (“key employee”).

• Any trustor (if the Borrower is owned by a trust).

• For a nonprofit organization, the officers and directors of the Borrower.

4. Principal Name. Insert the full name of the Principal.

5. Position. Identify the Principal’s position; for example, self-employed individual; independent contractor; sole proprietor; general partner; owner;

officer; director; member; or key employee.

Paperwork Reduction Act – You are not required to respond to this collection of information unless it displays a currently valid OMB Control Number. 

The estimated time for completing this application, including gathering data needed, is 8 minutes. Comments about this time or the information requested 

should be sent to: Small Business Administration, Director, Records Management Division, 409 3rd St., SW, Washington DC 20416, and/or SBA Desk 

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

ADDRESSES. 

Privacy Act (5 U.S.C. 552a) – Under the provisions of the Privacy Act, you are not required to provide your social security number. Failure to provide your 

social security number may not affect any right, benefit or privilege to which you are entitled. (But see Debt Collection Notice regarding taxpayer 

identification number below.) Disclosures of name and other personal identifiers are required to provide SBA with sufficient information to make a character 

determination. When evaluating character, SBA considers the person’s integrity, candor, and disposition toward criminal actions. Additionally, SBA is 

specifically authorized to verify your criminal history, or lack thereof, pursuant to section 7(a)(1)(B), 15 USC Section 636(a)(1)(B) of the Small Business 

Act. 

Disclosure of Information – Requests for information about another party may be denied unless SBA has the written permission of the individual to release 

the information to the requestor or unless the information is subject to disclosure under the Freedom of Information Act. The Privacy Act authorizes SBA 

to make certain “routine uses” of information protected by that Act. One such routine use is the disclosure of information maintained in SBA’s system of 

records when this information indicates a violation or potential violation of law, whether civil, criminal, or administrative in nature. Specifically, SBA may 

refer the information to the appropriate agency, whether Federal, State, local or foreign, charged with responsibility for, or otherwise involved in 

investigation, prosecution, enforcement or prevention of such violations. Another routine use is disclosure to other Federal agencies conducting background 

checks but only to the extent the information is relevant to the requesting agencies’ function. See, 74 F.R. 14890 (2009), and as amended from time to time 

for additional background and other routine uses. In addition, the CARES Act, requires SBA to register every loan made under the Paycheck Protection 

Program using the Taxpayer Identification Number (TIN) assigned to the borrower. 

Debt Collection Act of 1982, Deficit Reduction Act of 1984 (31 U.S.C. 3701 et seq. and other titles) – SBA must obtain your taxpayer identification 

number when you apply for a loan. If you receive a loan, and do not make payments as they come due, SBA may: (1) report the status of your loan(s) to 

credit bureaus, (2) hire a collection agency to collect your loan, (3) offset your income tax refund or other amounts due to you from the Federal Government, 

(4) suspend or debar you or your company from doing business with the Federal Government, (5) refer your loan to the Department of Justice, or (6) take

other action permitted in the loan instruments.

Right to Financial Privacy Act of 1978 (12 U.S.C. 3401) – The Right to Financial Privacy Act of 1978, grants SBA access rights to financial records held 

by financial institutions that are or have been doing business with you or your business including any financial institutions participating in a loan or loan 

guaranty. SBA is only required provide a certificate of its compliance with the Act to a financial institution in connection with its first request for access to 

your financial records. SBA’s access rights continue for the term of any approved loan guaranty agreement. SBA is also authorized to transfer to another 

Government authority any financial records concerning an approved loan or loan guarantee, as necessary to process, service or foreclose on a loan guaranty 

or collect on a defaulted loan guaranty. 

Freedom of Information Act (5 U.S.C. 552) – This law provides, with some exceptions, that SBA must supply information reflected in agency files and 

records to a person requesting it. Information about approved loans that is generally released includes, among other things, statistics on our loan programs 

(individual borrowers are not identified in the statistics) and other information such as the names of the borrowers, the amount of the loan, and the type of 

the loan. Proprietary data on a borrower would not routinely be made available to third parties. All requests under this Act are to be addressed to the nearest 

SBA office and be identified as a Freedom of Information request. 

SBA Form 2483-SD (2/21) 6 
 

 

 

 

 

 

 

 

 

 

Paycheck Protection Program 

Second Draw Borrower Application Form Revised February 17, 2021 

Occupational Safety and Health Act (15 U.S.C. 651 et seq.) – The Occupational Safety and Health Administration (OSHA) can require businesses to 

modify facilities and procedures to protect employees. Businesses that do not comply may be fined and required to abate the hazards in their workplaces. 

They may also be ordered to cease operations posing an imminent danger of death or serious injury until employees can be protected. Signing this form is 

certification that the applicant, to the best of its knowledge, is in compliance with the applicable OSHA requirements, and will remain in compliance during 

the life of the loan. 

Civil Rights (13 C.F.R. 112, 113, 117) – All businesses receiving SBA financial assistance must agree not to discriminate in any business practice, including 

employment practices and services to the public on the basis of categories cited in 13 C.F.R., Parts 112, 113, and 117 of SBA Regulations. All borrowers 

must display the "Equal Employment Opportunity Poster" prescribed by SBA. 

Equal Credit Opportunity Act (15 U.S.C. 1691) – Creditors are prohibited from discriminating against credit applicants on the basis of race, color, religion, 

national origin, sex, marital status or age (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant’s 

income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection 

Act. 

Debarment and Suspension Executive Order 12549 (2 C.F.R. Part 180 and Part 2700) – By submitting this loan application, you certify that neither 

the Applicant or any owner of the Applicant have within the past three years been: (a) debarred, suspended, declared ineligible or voluntarily excluded from 

participation in a transaction by any Federal Agency; (b) formally proposed for debarment, with a final determination still pending; (c) indicted, convicted, 

or had a civil judgment rendered against you for any of the offenses listed in the regulations or (d) delinquent on any amounts owed to the U.S. Government 

or its instrumentalities as of the date of execution of this certification. 

SBA Form 2483-SD (2/21) 7