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Please Sign PPP Origination Application - PDF B
Please Sign PPP Origination Application - PDF B
Please Sign PPP Origination Application - PDF B
AN APPLICANT MAY USE THIS FORM ONLY IF THE APPLICANT FILES AN IRS FORM 1040, SCHEDULE C, AND
USES GROSS INCOME TO CALCULATE PPP LOAN AMOUNT
Check One: Sole proprietor DBA or Tradename (if applicable) Year of Establishment (if applicable)
Independent contractor
✔
Self-employed individual
Single member LLC (self-employed
individual) Caterer 01/01/2015
Qualified joint venture (self-employed
individual)
Applicant (including affiliates, if
Business Legal Name NAICS Code applicable) Meets Size Standard (check
one):
✔ No more than 500 employees (or 300
Telesforo Chuidian employees, if applicable) unless “per
722320 location” exception applies
SBA industry size standards
SBA alternative size standard
Business Address (Street, City, State, Zip Code - No P.O. Box
Business TIN (EIN, SSN, ITIN) Business Phone
addresses allowed)
If you do not have any employees (other than owners), complete this table:
A. Your gross income x 2.5 + EIDL (Do Not
B. Divide A by 12 (if
amount from 2019 or 2020 Include Any EIDL
$ $106,121.00 more than $8,333.33, $ $8,333.33 $ $20,833.00
IRS Form 1040, Schedule Advance) equals Loan
enter $8,333.33):
C, line 7: Request Amount:
☐
✔ Payroll Costs (including
☐ Rent /
proprietor expenses, equal to ☐ Covered Operations
Mortgage ☐ Utilities
Purpose of the loan business expenses plus owner Expenditures
Interest
(select all that compensation)
apply):
☐ Covered Property ☐ Covered ☐ Covered Worker ☐ Other (explain):
Damage Supplier Costs Protection Expenditures ______________________
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
ITIN)
See Attached Table
Race (more than 1 ☐ American Indian or Alaska Native; ☐ Asian; ☐ Black or African-American;
may be selected) ☐ Native Hawaiian or Pacific Islander; ☐ White; ☐ Not Disclosed
Ethnicity ☐ Hispanic or Latino; ☐ Not Hispanic or Latino; ☐
✔ Not Disclosed
If questions (1), (2), (5), or (6) 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 (other than a Federal student loan made or guaranteed through a program ✔
administered by the Department of Education) 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 addendum A.
4. Did the Applicant receive 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.
5. Is the Applicant (if an individual) or any owner 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 5 → _____________________
<<initialHere>>
6. 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, 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 6 → _____________________
<<initialHere>>
7. Is the United States the principal place of residence for the owner(s) of the Applicant and all employees included in the Applicant’s
✔
payroll calculation above?
8. Is the Applicant a franchise? ✔
9. Is the franchise listed in SBA’s Franchise Directory? If yes, enter SBA Franchise Identifier Code here: _______________ ✔
<<initialHere>> 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.
<<signHere>>
_________________________________________________________ ________________________
05-18-2021
Signature of Authorized Representative of Applicant Date
___________________________________________
Telesforo Chuidian ________________________
Owner
Print Name Title
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.
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.
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.
Demographics
American Native Not
Principal Name Position Veteran Gender Indian Asian Black Islander White Disclosed Ethnicity
Telesforo Chuidian Not Disclosed X X X
DocuSign Envelope ID: 312A177F-56A6-476F-BF20-A4004F6DA3C4
Applicant Ownership
Owner Name Title Ownership % TIN (EIN,SSN) Address
Telesforo Chuidian Owner 100 552375391 8460 West Gilmore Ave Las Vegas, NV 89129
Certificate Of Completion
Envelope Id: 312A177F56A6476FBF20A4004F6DA3C4 Status: Completed
Subject: Please Sign PPP_Origination_Application.pdf Below
Source Envelope:
Document Pages: 8 Signatures: 1 Envelope Originator:
Certificate Pages: 4 Initials: 12 Womply PPP Admin
AutoNav: Enabled 24422 Avenida De La Carlota
EnvelopeId Stamping: Enabled Laguna Hills, CA 92653
Time Zone: (UTC-08:00) Pacific Time (US & Canada) esign-2091-hsbf@teslarsoftware.com
IP Address: 174.47.181.211
Record Tracking
Status: Original Holder: Womply PPP Admin Location: DocuSign
5/18/2021 6:31:10 AM esign-2091-hsbf@teslarsoftware.com
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