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Paycheck Protection Program
Application Form
OMB Control No.: 3245-
Expiration Date: 06/30/2020
1
SBA Form 2483 (03/20)
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Non-Profit ☐ Vet Org ☐ Tribal ☐ Ind. Cont. ☐ Self Employed ☐
DBA or Tradename if applicable
Business Legal Name
Business Primary Address
Business TIN (EIN,SSN)
Business Phone
( ) -
Primary Contact
Email Address
Average Monthly Payroll:
$
X 2.5 equals Loan Amount:
$
Number of Jobs:
Purpose of the loan
(select more than one):
☐Payroll ☐Rent / Mortgage Interest ☐Utilities ☐Other (explain):__________________
Applicant Ownership
List all owners of Applicant with greater than 20% ownership stakes. Attach a separate sheet if necessary.
Owner Name
Title
Ownership %
TIN (EIN,SSN)
Address
If questions (1) or (2) below are answered “Yes,” the loan will not be approved.
Question
Yes No
1.
Is the Business or any owner 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 Business, any of its owners, 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 currently delinquent or has defaulted in the last 7 years and caused a loss to
the government?
3.
Is the Business or any owner an owner of any other business or have common management with any other business? If yes,
attach a listing of all Affiliates and describe the relationship as addendum A.
4. Has the Business received an SBA Economic Injury Disaster Loan between January 31, 2020 and April 3, 2020? If yes,
provide details on a separate sheet identified as addendum B.
Applicants who are individuals and all 20% or greater owners of the business must answer the following questions. If