"Loan Application Form - Statement for 912 Secondary Clearance - Capital Cdc"

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SBA 504 Loan Application
Statement for 912 Secondary Clearance
NOTE: Complete if you had an SBA Form 912 w/ Fingerprint Cards cleared in the past
and have no cause to answer “YES” to Questions 8 and/or 9 for more recent Incidents
Full Legal Name: ________________________________________________________________
SSN: __________________ Date of Birth: _______________ Telephone: _________________
Home Address (Street): ___________________________________________________________
City: ________________________________ State: _________ ZIP Code: _________________
Project Business Name: ___________________________________________________________
Estimated Debenture Amount: _____________ Estimated Submission Date: _______________
*1) all documentation used in the original submission/clearance must accompany this request
* 2) new Fingerprint Cards must be obtained and be submitted with this request
I, (PRINT FULL LEGAL NAME) __________________________________________________, do hereby
attest and affirm that the information provided herein and on the provided SBA Form 912 dated
______________________ is complete, that I have not had any additional Incidents or Charges since the
SBA Form 912 dated ______________________ that was cleared by SBA on _____________________,
and that I do not have any other Charges, Arrests, or Incidents as described in Questions 8 and 9 on SBA
Form 912 to disclose, under penalty of law as noted below.
Signature: _______________________________________
Date: _________________________
Signer certifies that all information provided to the CDC and submitted with this loan application to the US Small Business Administration is true
and complete to the best of his/her knowledge, and that any false statement or report may be punished by a fine of up to $1,000,000 or by
imprisonment for up to 30 years, or both, pursuant to 18 U.S.C. 1014, and further can result in civil money penalties and additional monetary
liability up to three times the amount of damages which the Government sustains because of the false statement under the False Claims Act, 31
U.S.C. 3729.
912 Secondary Clearance Form Version 2015-06
SBA 504 Loan Application
Statement for 912 Secondary Clearance
NOTE: Complete if you had an SBA Form 912 w/ Fingerprint Cards cleared in the past
and have no cause to answer “YES” to Questions 8 and/or 9 for more recent Incidents
Full Legal Name: ________________________________________________________________
SSN: __________________ Date of Birth: _______________ Telephone: _________________
Home Address (Street): ___________________________________________________________
City: ________________________________ State: _________ ZIP Code: _________________
Project Business Name: ___________________________________________________________
Estimated Debenture Amount: _____________ Estimated Submission Date: _______________
*1) all documentation used in the original submission/clearance must accompany this request
* 2) new Fingerprint Cards must be obtained and be submitted with this request
I, (PRINT FULL LEGAL NAME) __________________________________________________, do hereby
attest and affirm that the information provided herein and on the provided SBA Form 912 dated
______________________ is complete, that I have not had any additional Incidents or Charges since the
SBA Form 912 dated ______________________ that was cleared by SBA on _____________________,
and that I do not have any other Charges, Arrests, or Incidents as described in Questions 8 and 9 on SBA
Form 912 to disclose, under penalty of law as noted below.
Signature: _______________________________________
Date: _________________________
Signer certifies that all information provided to the CDC and submitted with this loan application to the US Small Business Administration is true
and complete to the best of his/her knowledge, and that any false statement or report may be punished by a fine of up to $1,000,000 or by
imprisonment for up to 30 years, or both, pursuant to 18 U.S.C. 1014, and further can result in civil money penalties and additional monetary
liability up to three times the amount of damages which the Government sustains because of the false statement under the False Claims Act, 31
U.S.C. 3729.
912 Secondary Clearance Form Version 2015-06