U.S. Department of the Treasury

State Small Business Credit Initiative 

Capital Program Sample Certifications

Updated July 20221

The State Small Business Credit Initiative (SSBCI) Capital Program Policy Guidelines (as they 

may be amended from time to time, the Guidelines) require certifications in various 

circumstances from lenders, investors, and small business borrowers and investees participating 

in SSBCI capital programs of participating jurisdictions.

2

 Treasury is providing sample 

certifications that may be used by participating jurisdictions for their capital programs. These 

sample certifications are provided for illustrative purposes only and are not intended to replace or 

supersede any internal controls participating jurisdictions have in place. Participating 

jurisdictions (or, as applicable, implementing entities, contracted entities, lenders, or investors) 

may design their own certification forms to meet the assurance and certification requirements in 

the Guidelines. The table lists the sample certifications and how they apply to different types of 

SSBCI capital programs, which include Capital Access Programs (CAPs), loan/credit Other 

Credit Support Programs (OCSPs), and venture capital/equity OCSPs. 

Sample Certification CAPs Loan/Credit 

OCSPs

Venture 

Capital/Equity 

OCSPs

1. Borrower/Investee Use of Proceeds 

and Conflict of Interest Certification

  

2. Lender/Investor Use of Proceeds and 

Conflict of Interest Certification

  

3. Sex Offender Lender/Borrower 

Certification (Loan/Credit Program)

 

4. Sex Offender Investor/Investee 

Certification (Venture Capital/Equity 

Program)



1 Capital Program Sample Certifications were initially released on June 2, 2022. The document was updated on 

July 27, 2022 to include Sample Certifications 7 and 8. 2

 The record retention requirements of Section VI of the SSBCI Capital Program Reporting Guidance apply to all 

records pertinent to a participating jurisdiction’s SSBCI capital allocation, including certifications of compliance 

with SSBCI requirements. 
Sample Certification CAPs Loan/Credit 

OCSPs

Venture 

Capital/Equity 

OCSPs

5. Borrower/Investee Certification 

Related to Business Enterprises 

Owned and Controlled by Socially 

and Economically Disadvantaged 

Individuals (SEDI-Owned 

Businesses)3

  

6. Certification Regarding Venture 

Capital Fund Services to Portfolio 

Companies



7. Borrower/Investee Use of Proceeds 

and Conflict of Interest Certification 

for a Tribal Enterprise Lending to or 

Investing in Another Tribal 

Enterprise4

 

8. Lender/Investor Use of Proceeds and 

Conflict of Interest Certification for a 

Tribal Enterprise Lending to or 

Investing in Another Tribal 

Enterprise5

 

3 SSBCI funds count toward fulfilling the “expended for” requirement for the $1.5 billion SEDI allocation and 

toward qualifying for initial eligible amounts under the $1.0 billion SEDI incentive allocation if the SSBCI funds 

have been expended for loans, investments, or other credit or equity support to any of the four groups of businesses 

set forth in Section IV.a of the Capital Program Policy Guidelines. While a participating jurisdiction may reasonably 

identify group (4) businesses (i.e., those located in Community Development Financial Institution (CDFI) 

Investment Areas) based on businesses’ addresses from the relevant loan, investment, and credit or equity support 

applications, certification is required with regard to groups (1) through (3).

4

 This certification can be used to obtain the borrower/investee use of proceeds and conflict of interest certification 

for a loan or investment that is part of a Tribal government OCSP and involves a Tribal enterprise lending to or 

investing in another Tribal enterprise. For transactions where a Tribal enterprise is not lending to or investing in 

another Tribal enterprise, use Sample Certification 1.

5 This certification can be used to obtain the lender/investor use of proceeds and conflict of interest certification for a 

loan or investment that is part of a Tribal government OCSP and involves a Tribal enterprise lending to or investing 

in another Tribal enterprise. For transactions where a Tribal enterprise is not lending to or investing in another Tribal 

enterprise, use Sample Certification 2.
Sample Certification 1 – Page 1

Sample Certification 1. Borrower/Investee Use of Proceeds and Conflict of Interest 

Certification

This sample certification may be used by a participating jurisdiction to obtain the applicable 

borrower or investee use of proceeds and conflict of interest certifications. This sample 

certification is provided for illustrative purposes only and is not intended to replace or supersede 

any internal controls a participating jurisdiction has in place. 

Funds from the State Small Business Credit Initiative (SSBCI) may only be used for certain 

purposes and in circumstances where the applicable conflict of interest standards are satisfied. 

Legal name of borrower ☐ or investee ☐: __________________________________________

The borrower or investee hereby certifies the following to the lender or investor:

1. The loan or investment proceeds will be used solely for a business purpose. A business 

purpose includes, but is not limited to, start-up costs; working capital; franchise fees; and 

acquisition of equipment, inventory, or services used in the production, manufacturing, or 

delivery of a business’s goods or services, or in the purchase, construction, renovation, or 

tenant improvements of an eligible place of business that is not for passive real estate 

investment purposes. SSBCI funds may be used to purchase any tangible or intangible assets 

except goodwill. The term “business purpose” excludes acquiring or holding passive 

investments in real estate; the purchase of securities except as permitted in certification 2.d 

below; and lobbying activities (as defined in Section 3(7) of the Lobbying Disclosure Act of 

1995, P.L. 104-65, as amended (2 U.S.C. § 1602(7)).

2. The loan or investment proceeds will not be used to:

a. repay delinquent federal or jurisdiction income taxes unless the borrower or investee has

a payment plan in place with the relevant taxing authority;

b. repay taxes held in trust or escrow (e.g., payroll or sales taxes);

c. reimburse funds owed to any owner, including any equity investment or investment of 

capital for the business’s continuance; or

d. purchase any portion of the ownership interest of any owner of the business, except for 

the purchase of an interest in an employee stock ownership plan qualifying under 

section 401 of Internal Revenue Code, worker cooperative, or related vehicle, provided 

that the transaction results in the employee stock ownership plan or other 

employee-owned entity holding a majority interest (on a fully diluted basis) in the 

business.

3. The borrower or investee is not:

a. a business engaged in speculative activities that profit from fluctuations in price, such as 

wildcatting for oil and dealing in commodities futures, unless those activities are 

incidental to the regular activities of the business and part of a legitimate risk 

management strategy to guard against price fluctuations related to the regular activities of 
Sample Certification 1 – Page 2

the business or through the normal course of trade;1

b. a business that earns more than half of its annual net revenue from lending activities, 

unless the business is (1) a CDFI that is not a depository institution or a bank holding 

company, or (2) a Tribal enterprise lender that is not a depository institution or a bank 

holding company;

c. a business engaged in pyramid sales, where a participant’s primary incentive is based on 

the sales made by an ever-increasing number of participants;

d. a business engaged in activities that are prohibited by federal law or, if permitted by 

federal law, applicable law in the jurisdiction where the business is located or conducted 

(this includes businesses that make, sell, service, or distribute products or services used in 

connection with illegal activity, unless such use can be shown to be completely outside of

the business’s intended market); this category of businesses includes direct and indirect 

marijuana businesses, as defined in Small Business Administration (SBA) Standard 

Operating Procedure (SOP) 50 10 6;2 or

e. a business deriving more than one-third of gross annual revenue from legal gambling 

activities, unless the business is a Tribal SSBCI participant, in which case the Tribal 

SSBCI participant is prohibited from using SSBCI funds for gaming activities, but is not 

restricted from using SSBCI funds for non-gaming activities merely due to an 

organizational tie to a gaming business.

3 For purposes of Tribal SSBCI programs, 

“gaming activities” includes only “class II gaming” and “class III gaming” as these terms 

are defined under the Indian Gaming Regulatory Act (IGRA), 25 U.S.C. § 2703.

For a borrower participating in a loan/credit program:

4. The borrower is not:

a. an executive officer, director, or principal shareholder of the lender;

b. a member of the immediate family of an executive officer, director, or principal 

shareholder of the lender; or

c. a related interest or immediate family member of such an executive officer, director, or 

principal shareholder of the lender.

For the purposes of the above conflict of interest certification, the terms “executive officer,” 

“director,” “principal shareholder,” “immediate family,” and “related interest” refer to the 

same relationship to the lender as the relationships described in 12 C.F.R. part 215.

1 A construction loan permitted under the guidance on passive real estate investment in the SSBCI Capital Program 

Policy Guidelines will not be considered a speculative business for purposes of SSBCI. 2 See chapter 3.A.8.b of SBA SOP 50 10 6 (effective October 1, 2020), which specifies the following with respect to 

marijuana-related businesses: “Because federal law prohibits the distribution and sale of marijuana, financial 

transactions involving a marijuana-related business would generally involve funds derived from illegal activity. 

Therefore, businesses that derive revenue from marijuana-related activities or that support the end-use of marijuana 

may be ineligible for SBA financial assistance.”

3 Under this standard, a gaming Tribal enterprise could apply for SSBCI funds for a new gas station, for example, 

even if the Tribal enterprise’s revenues from gaming were greater than 33 percent.
Sample Certification 1 – Page 3 

For an investee participating in a venture capital/equity program: 

5. The investee is compliant with the venture capital program conflict of interest standards set 

forth in Section VIII.f of the SSBCI Capital Program Policy Guidelines. Briefly, these 

standards provide that no SSBCI insider, or a family member or business partner of an 

SSBCI insider, has a personal financial interest in the investee unless an exception specified 

in Section VIII.f of the SSBCI Capital Program Policy Guidelines applies. The terms “SSBCI 

insider,” “family member,” “business partner,” and “personal financial interest” have the 

meanings set forth in Section VIII.f of the SSBCI Capital Program Policy Guidelines. 

If an exception applies, it must be specified here:

The undersigned is an authorized representative of the borrower or investee. 

Signature: 

Name: 

Title: 

Date: 
Sample Certification 2 – Page 1 

Sample Certification 2. Lender/Investor Use of Proceeds and Conflict of Interest 

Certification

This sample certification may be used by a participating jurisdiction to obtain the applicable 

lender or investor use of proceeds and conflict of interest certifications. This sample certification 

is provided for illustrative purposes only and is not intended to replace or supersede any internal 

controls a participating jurisdiction has in place. 

Funds from the State Small Business Credit Initiative (SSBCI) may only be used for certain 

purposes and in circumstances where the applicable conflict of interest standards are satisfied. 

Legal name of lender ☐ or investor ☐: ____________________________________________ 

The lender or investor hereby certifies the following to the participating jurisdiction: 

1. The SSBCI-supported loan or investment is not being made in order to place under the 

protection of the approved program prior debt that is not covered under the approved 

program and that is or was owed by the borrower/investee to the lender/investor or to an 

affiliate of the lender/investor. 

2. If the SSBCI-supported loan is a refinancing, it complies with all applicable SSBCI 

restrictions and requirements in Sections VII.f and VIII.f of the SSBCI Capital Program 

Policy Guidelines regarding refinancing and new extensions of credit, including that the 

SSBCI-supported loan is not a refinancing of a loan previously made to the borrower by the 

lender or an affiliate of the lender. 

3. The lender or investor is not attempting to enroll any portion of an SBA-guaranteed loan. 

4. For an SSBCI-supported venture capital or equity investment, the investment complies with 

the venture capital program conflict of interest standards as set forth in Section VIII.f of the 

SSBCI Capital Program Policy Guidelines. 

The undersigned is an authorized representative of the lender or investor. 

Signature: 

Name: 

Title: 

Date: 
Sample Certification 3 – Page 1 

Sample Certification 3. Sex Offender Lender/Borrower Certification 

(Loan/Credit Program) 

This sample certification may be used by a participating jurisdiction to obtain the applicable 

lender or borrower sex offender certification. This sample certification is provided for 

illustrative purposes only and is not intended to replace or supersede any internal controls a 

participating jurisdiction has in place. 

Under the State Small Business Credit Initiative (SSBCI), lenders and borrowers must certify 

that their principals have not been convicted of a sex offense against a minor. 

Legal name of lender ☐ or borrower ☐: 

The lender or borrower hereby certifies the following to the participating jurisdiction: 

No principal of the entity listed above has been convicted of a sex offense against a minor (as 

such terms are defined in 34 U.S.C. § 20911). For the purposes of this certification, “principal” 

means the following: if a sole proprietorship, the proprietor; if a partnership, each partner; if a 

corporation, limited liability company, association, development company, or other entity, each 

director, each of the five most highly compensated executives, officers, or employees of the 

entity, and each direct or indirect holder of 20 percent or more of the ownership stock or stock 

equivalent of the entity. 

The undersigned is an authorized representative of the lender or borrower. 

Signature: 

Name: 

Title: 

Date: 
Sample Certification 4 – Page 1 

Sample Certification 4. Sex Offender Investor/Investee Certification 

(Venture Capital/Equity Program) 

This sample certification may be used by a participating jurisdiction to obtain the applicable 

investor or investee sex offender certification. This sample certification is provided for 

illustrative purposes only and is not intended to replace or supersede any internal controls a 

participating jurisdiction has in place. 

Under the State Small Business Credit Initiative (SSBCI), investors and investees must certify 

that their principals have not been convicted of a sex offense against a minor. 

Legal name of investor ☐ or investee ☐: 

The investor or investee hereby certifies the following to the participating jurisdiction: 

No principal of the entity listed above, has been convicted of a sex offense against a minor (as 

such terms are defined in 34 U.S.C. § 20911). For the purposes of this certification, “principal” is 

defined as if a sole proprietorship, the proprietor; if a partnership, each managing partner and 

each partner who is a natural person and holds 50 percent or more ownership interest of any class 

of the partnership interests; if a corporation, limited liability company, association, development 

company, or other entity, each director, each of the five most highly compensated executives or 

officers of the entity, and each natural person who is a direct or indirect holder of 50 percent or 

more of any class of equity interest in the entity; and if a partnership where the managing partner 

is a corporation, limited liability company, association, development company, or other entity, 

each director and each of the five most highly compensated executives or officers of the entity.

The undersigned is an authorized representative of the investor or investee. 

Signature: 

Name: 

Title: 

Date: 
Sample Certification 5 – Page 1 

Sample Certification 5. Borrower/Investee Certification Related to Business Enterprises 

Owned and Controlled by Socially and Economically Disadvantaged Individuals 

(SEDI-Owned Businesses)

This sample certification may be used by a participating jurisdiction to obtain the applicable 

SEDI-owned business certification. This sample certification is provided for illustrative purposes 

only and is not intended to replace or supersede any internal controls a participating jurisdiction 

has in place. 

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 

known as participating jurisdictions). SSBCI programs are designed to expand access to capital, 

promote economic resiliency, and create new jobs and economic opportunity. SSBCI provides 

funding for participating jurisdictions to support businesses owned and controlled by socially and 

economically disadvantaged individuals (SEDI-owned businesses).1 This certification provides 

documentation that an SSBCI loan or investment supported a SEDI-owned business. The 

information collected from this certification 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 antidiscrimination laws, including, but not limited to, the laws specified in Section IX.b of the 

Capital Program Policy Guidelines (Compliance with Civil Rights Requirements). 

The borrower or investee is not required to provide this certification. The borrower or investee 

may identify all categories in groups (1) through (3) below that apply, including all subcategories 

in group (1) that apply. 

Legal name of borrower ☐ or investee ☐: 

The borrower or investee hereby certifies to the lender or investor that it is a: 

1. Business enterprise that is owned and controlled2 by individuals who have had their access to 

credit on reasonable terms diminished as compared to others in comparable economic 

circumstances, due to their: 

☐ membership of a group that has been subjected to racial or ethnic prejudice or cultural 

bias within American society; 

1 SSBCI funds count toward fulfilling the “expended for” requirement for the $1.5 billion SEDI allocation and 

toward qualifying for initial eligible amounts under the $1.0 billion SEDI incentive allocation if the SSBCI funds 

have been expended for loans, investments, or other credit or equity support to any of the four groups of businesses 

set forth in Section IV.a of the SSBCI Capital Program Policy Guidelines. While a participating jurisdiction may 

reasonably identify group (4) businesses (i.e., those located in Community Development Financial Institution 

(CDFI) Investment Areas) based on businesses’ addresses from the relevant loan, investment, and credit or equity 

support applications, certification is required with regard to groups (1) through (3).

2

 The term “owned and controlled” means, if privately owned, 51 percent is owned by such individuals; if publicly 

owned, 51 percent of the stock is owned by such individuals; and in the case of a mutual institution, a majority of 

the board of directors, account holders, and the community of which the institution services is predominantly 

comprised of such individuals.
Sample Certification 5 – Page 2 

☐ gender; 

☐ veteran status; 

☐ limited English proficiency; 

☐ disability; 

☐ long-term residence in an environment isolated from the mainstream of American 

society; 

☐ membership of a federally or state-recognized Indian Tribe; 

☐ long-term residence in a rural community; 

☐ residence in a U.S. territory; 

☐ residence in a community undergoing economic transitions (including communities 

impacted by the shift towards a net-zero economy or deindustrialization); or 

☐ membership of another underserved community.3 

2. ☐ Business enterprise that is owned and controlled by individuals whose residences are in 

CDFI Investment Areas, as defined in 12 C.F.R. § 1805.201(b)(3)(ii).4

 

Individual(s)’ Address(es) in CDFI Investment Areas: 

3. ☐ Business enterprise that will build, open, or operate a location in a CDFI Investment Area, 

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

Business Address in CDFI Investment Area:

3

 “Underserved communities” are populations sharing a particular characteristic, as well as geographic communities, 

that have been systematically denied a full opportunity to participate in aspects of economic, social, and civic life, as 

exemplified by the list in the definition of equity. Equity is consistent and systematic fair, just, and impartial 

treatment of all individuals, including individuals who belong to underserved communities that have been denied 

such treatment, such as Black, Latino, and Indigenous and Native American persons, Asian Americans and Pacific 

Islanders and other persons of color; members of religious minorities; lesbian, gay, bisexual, transgender, and queer 

(LGBTQ+) persons; persons with disabilities; persons who live in rural areas; and persons otherwise adversely 

affected by persistent poverty or inequality.

4 Treasury has provided a mapping tool for the borrower or investee to use to identify whether the relevant address is 

in a CDFI Investment Area at https://home.treasury.gov/policy-issues/small-business-programs/state-small-businesscredit-initiative-ssbci/2021-ssbci/cdfi-fund-investment-areas. For each calendar year, Treasury will use the list of 

CDFI Investment Areas identified by the CDFI Fund as of January 1 of the calendar year. If the CDFI Fund’s list is 

updated during that calendar year, the new list will not be adopted for purposes of SSBCI until the next calendar 

year, thus providing advance notice to jurisdictions. Further, Treasury has determined that American Samoa, Guam, 

the Northern Mariana Islands, and the U.S. Virgin Islands in their entirety constitute CDFI Investment Areas for 

purposes of the SSBCI, because each of these territories has a poverty rate of at least 20 percent. 
Sample Certification 5 – Page 3 

The undersigned is an authorized representative of the borrower or investee. 

Signature: 

Name: 

Title: 

Date: 
Sample Certification 6 – Page 1 

Sample Certification 6. Certification Regarding Venture Capital Fund Services to 

Portfolio Companies

This sample certification may be used by a participating jurisdiction to obtain the applicable 

certification regarding venture capital fund services to portfolio companies. This sample 

certification is provided for illustrative purposes only and is not intended to replace or supersede 

any internal controls a participating jurisdiction has in place. 

Under the State Small Business Credit Initiative (SSBCI), if the participating jurisdiction uses up 

to an annual average of 1.71 percent of the federal contribution to pay for services to portfolio 

companies over the life of the jurisdiction’s venture capital program, then the venture capital 

fund must annually certify that such services were provided. 

Legal name of venture capital fund: 

The venture capital fund hereby certifies that services to portfolio companies as identified in the 

agreement between the above venture capital fund and the participating jurisdiction were 

provided in __________ (year). 

The undersigned is an authorized representative of the venture capital fund. 

Signature: 

Name: 

Title: 

Date: 
Sample Certification 7 – Page 1 

Sample Certification 7. Borrower/Investee Use of Proceeds and Conflict of Interest 

Certification for a Tribal Enterprise Lending to or Investing in Another Tribal Enterprise

This sample certification may be used by Tribal governments to obtain the applicable borrower 

or investee use of proceeds and conflict of interest certifications for a loan or investment that is 

part of a Tribal OCSP and involves a Tribal enterprise lending to or investing in another 

Tribal enterprise. For Tribal government OCSP transactions where a Tribal enterprise is not 

lending to or investing in another Tribal enterprise, refer to Sample Certification 1. This sample 

certification is provided for illustrative purposes only and is not intended to replace or supersede 

any internal controls a Tribal government has in place.

Funds from the State Small Business Credit Initiative (SSBCI) may only be used for certain 

purposes and in circumstances where the applicable conflict of interest standards are satisfied.

Legal name of Tribal enterprise borrower ☐ or investee ☐: _____________________________ 

The Tribal enterprise borrower or investee hereby certifies the following to the Tribal enterprise 

lender or investor: 

1. The loan or investment proceeds will be used solely for a business purpose. A business 

purpose includes, but is not limited to, start-up costs; working capital; franchise fees; and 

acquisition of equipment, inventory, or services used in the production, manufacturing, or 

delivery of a business’s goods or services, or in the purchase, construction, renovation, or 

tenant improvements of an eligible place of business that is not for passive real estate 

investment purposes. SSBCI funds may be used to purchase any tangible or intangible assets 

except goodwill. The term “business purpose” excludes acquiring or holding passive 

investments in real estate; the purchase of securities except as permitted in certification 2.d

below; and lobbying activities (as defined in Section 3(7) of the Lobbying Disclosure Act of 

1995, P.L. 104-65, as amended (2 U.S.C. § 1602(7)). 

2. The loan or investment proceeds will not be used to:

a. repay delinquent federal or jurisdiction income taxes unless the borrower or 

investee has a payment plan in place with the relevant taxing authority; 

b. repay taxes held in trust or escrow (e.g., payroll or sales taxes); 

c. reimburse funds owed to any owner, including any equity investment or investment 

of capital for the business’s continuance; or 

d. purchase any portion of the ownership interest of any owner of the business, except for 

the purchase of an interest in an employee stock ownership plan qualifying under 

section 401 of Internal Revenue Code, worker cooperative, or related vehicle, provided 

that the transaction results in the employee stock ownership plan or other 

employee-owned entity holding a majority interest (on a fully diluted basis) in the 

business.

3. The borrower or investee is not: 

a. a business engaged in speculative activities that profit from fluctuations in price, such as 

wildcatting for oil and dealing in commodities futures, unless those activities are 
Sample Certification 7 – Page 2

incidental to the regular activities of the business and part of a legitimate risk 

management strategy to guard against price fluctuations related to the regular activities of 

the business or through the normal course of trade;1

b. a business that earns more than half of its annual net revenue from lending activities, 

unless the business is (1) a CDFI that is not a depository institution or a bank holding 

company, or (2) a Tribal enterprise lender that is not a depository institution or a bank 

holding company;

c. a business engaged in pyramid sales, where a participant’s primary incentive is based on 

the sales made by an ever-increasing number of participants;

d. a business engaged in activities that are prohibited by federal law or, if permitted by 

federal law, applicable law in the jurisdiction where the business is located or conducted 

(this includes businesses that make, sell, service, or distribute products or services used in 

connection with illegal activity, unless such use can be shown to be completely outside of 

the business’s intended market); this category of businesses includes direct and indirect 

marijuana businesses, as defined in Small Business Administration (SBA) Standard 

Operating Procedure (SOP) 50 10 6;2 or

e. a business deriving more than one-third of gross annual revenue from legal gambling 

activities, unless the business is a Tribal SSBCI participant, in which case the Tribal 

SSBCI participant is prohibited from using SSBCI funds for gaming activities, but is not 

restricted from using SSBCI funds for non-gaming activities merely due to an 

organizational tie to a gaming business.3 For purposes of Tribal SSBCI programs, 

“gaming activities” includes only “class II gaming” and “class III gaming” as these terms 

are defined under the Indian Gaming Regulatory Act (IGRA), 25 U.S.C. § 2703.

4. The loan or investment is in accordance with the Tribal conflict-of-interest policy, which was 

provided to and reviewed by the borrower or investee.

5. The borrower or investee understands that the lender or investor will publicly disclose this

loan or investment. 

1 A construction loan permitted under the guidance on passive real estate investment in the SSBCI Capital Program 

Policy Guidelines will not be considered a speculative business for purposes of SSBCI.

2 See chapter 3.A.8.b of SBA SOP 50 10 6 (effective October 1, 2020), which specifies the following with respect to 

marijuana-related businesses: “Because federal law prohibits the distribution and sale of marijuana, financial 

transactions involving a marijuana-related business would generally involve funds derived from illegal activity. 

Therefore, businesses that derive revenue from marijuana-related activities or that support the end-use of marijuana 

may be ineligible for SBA financial assistance.”

3 Under this standard, a gaming Tribal enterprise could apply for SSBCI funds for a new gas station, for example, 

even if the Tribal enterprise’s revenues from gaming were greater than 33 percent.
Sample Certification 7 – Page 3 

The undersigned is an authorized representative of the borrower or investee. 

Signature: 

Name: 

Title: 

Date: 
Sample Certification 8 – Page 1 

Sample Certification 8. Lender/Investor Use of Proceeds and Conflict of Interest 

Certification for a Tribal Enterprise Lending to or Investing in Another Tribal Enterprise

This sample certification may be used by Tribal governments to obtain the applicable lender or 

investor use of proceeds and conflict of interest certifications for a loan or investment that is part 

of a Tribal government OCSP and involves a Tribal enterprise lending to or investing in another 

Tribal enterprise. For Tribal government OCSP transactions where a Tribal enterprise is not 

lending to or investing in another Tribal enterprise, refer to Sample Certification 2. This sample 

certification is provided for illustrative purposes only and is not intended to replace or supersede 

any internal controls a Tribal government has in place. 

Funds from the State Small Business Credit Initiative (SSBCI) may only be used for certain 

purposes and in circumstances where the applicable conflict of interest standards are satisfied. 

Legal name of Tribal enterprise lender ☐ or investor ☐: _______________________________ 

The lender or investor hereby certifies the following: 

1. The SSBCI-supported loan or investment is not being made in order to place under the 

protection of the approved program prior debt that is not covered under the approved 

program and that is or was owed by the borrower/investee to the lender/investor or to an 

affiliate of the lender/investor. 

2. If the SSBCI-supported loan is a refinancing, it complies with all applicable SSBCI 

restrictions and requirements in Sections VII.f and VIII.f of the SSBCI Capital Program 

Policy Guidelines regarding refinancing and new extensions of credit, including that the 

SSBCI-supported loan is not a refinancing of a loan previously made to the borrower by the 

lender or an affiliate of the lender. 

3. The lender or investor is not attempting to enroll any portion of an SBA-guaranteed loan.

4. The loan or investment is in accordance with the Tribal conflict-of-interest policy which 

addresses conflicts arising from immediate family and self-dealing and has enforcement 

mechanisms for violations of the policy. 

5. The lender or investor will publicly disclose this loan or investment. 

The undersigned is an authorized representative of the lender or investor. 

Signature: 

Name: 

Title: 

Date: