Application for Surety Bond Guarantee Assistance (United States)
This is a Small Business Administration (SBA) application for surety bond guarantee assistance. The form provided here is simply a sample of what the actual Form 994 looks like.
U.S. Small Business Administration
Application for Surety Bond Guarantee Assistance
To be completed by principal
Trade name of principal _____________________________
Principal's business address _____________________________
Zip Code _____________________________
Principal's employer ID number _____________________________
To be completed by broker, agent (producer)
Name of surety _____________________________
Name of broker agent (producer) _____________________________
Broker Agent (Producer's) address _____________________________
Zip Code _____________________________
Broker agent (Producer(s) Telephone Number (include Area Code)
Broker/Agent (Producer's) Employer ID number
1. Applicant hereby states and affirms the following:
a. The annual gross receipt of my business (including affiliates, as set forth in Part 121 of SBA's Rules and Regulations) as annually averaged over the past fiscal years,
was $_____________________________ (to the nearest hundreds). If there are affiliates, attach an explanation sheet, delineating annual gross receipts of each as their interests appear. If there are stockholders, attach an explanation sheet specifying what their shares of the organization(s) are.
Type of business: ____ Proprietorship ____ Partnership ____ Corporation
Month: Date and Year Business Formed: ______________________
Joint Venture ____ Yes ____ No
Number of Employees _____________________________
b. A bid, payment or performance fond is required on the following project in order for me to serve as a
____ primary contractor or ____ subcontractor thereon
c. Contractor certifies having attempted (and failed) to obtain the required bonds without the SBA's guarantee; furthermore, the contractor certifies being aware that some suretees charge higher premiums rates for bonds than others do, in accordance with premium rate schedules filed in various states.
d. (1) Brief description of this contract work: _____________________________
(2) Estimated time required for completion: ___________ (months)
Contract have liquidated damages? ____ Yes ____ No
If "yes", how much? $_____________________________ per calendar of wkg. Day.
(3) Anticipated project start date _____________________________
(4) Projected completion date: _____________________________
(5) Project location: _____________________________
e. Subcontractor involved in this job? ____ Yes ____ No
If yes, Contractor certifies that subcontractor participation in work under contract is
f. Approximate value of contract: $_____________________________
g. Applicant, in consideration of assistance from the SBA herewith agrees it will comply with the nondiscrimination requirements of Title 13, Code of Federal Regulations, Part 113 and Executive Order 11246.
h. SBA is authorized to request this information under Executive Order 11625. It will be used only for statistical purposes. You are not required to disclose this information. Failure to do so will not affect your application.
(1) Principal is a ____ Veteran ____ Vietnam-era Veteran or ____ Non-veteran (Check One)
(2) Principal is a ____ Male ____ Female
(3) Principal is a (0) ____ Black
(1) ____ Puerto Rican
(2) ____ American Indian
(3) ____ Hispanic (other than Puerto Rican); Includes Mexican, Cuban, Central or South American or others of Spanish Descent
(4) ____ Asian (includes original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or Pacific Islands)
(5) ____ Eskimos and Aleuts
(6) ____ Undetermined
(7) ____ White
(8) ____ Multi-group
2. The date, time and place of the bid opening is as follows (if applicable):
3. I have read the "Contractor's Fee" section (reverse side) and agree to abide by this fee schedule. PROVIDED I receive the contract sought and BA extends its bond guarantee.
4. I ____ do not have an SBA Loan
____ I had a previous SBA Loan
____ I do have an SBA Loan through the SBA Office in
with a balance of $_____________________________
as of (Date) _____________________________
Loan No. _____________________________
5. I ____ am not an SBA 8(a) qualified contractor (approved business plan on file)
The bond application ____ does ____ does not pertain to an 8(a) contract
6. I ____ do ____ do not request Business Development Assistant
I ____ have ____ have not previously received SBA Business Development Assistance.
7. I ____ have ____ have not received previous SBA bond guarantee either under this trade name or another.
If under another trade name, specify:
Trade Name: _____________________________
When? 20______ to 20______
8. Have you ever defaulted on any previous surety bonds (SBA or other) (either under this contracting concern's trade name or any other concern's of which you have been a principal)?
____ Yes ____ No
If "yes", detailed particulars are to be attached to all four (4) copies of this application from. Particulars should include at least the following (1) Name of Surety; (2) Name of obligee; (SBG No. with suffix number, if applicable; (4) value of contracts; (5) date of default; (6) status of default claim; i.e., amount of loss to surety, etc.; (7) contractor's narrative explanation as to reason for default and actions taken to meet the obligations to the surety under term of the bond(s) to be guaranteed by SBA?
9. Have you made, or are you planning to make any payments, except for premiums, to the surety or agent for whatever purpose as a condition of, or in connection with, the issuance of the bond(s) to be guaranteed by SBA?
____ Yes ____ No If "yes", detailed particulars are to be attached to all four (4) copies of this application form.
10. Applicant hereby authorizes any agent, broker, surety company or financial institution in possession of credit, financial or work experience information concerning the undersigned applicant and the applicant's business to release the same to SBA, in order that SBA may evaluate the same for the purpose of bond guarantee assistance. Applicant certifies that any information he submits to any agent, broker or Surety Company for their evaluation as to the bondability of this contractor is correct and accurate to the best of the contractor's knowledge.
11. Any intentionally false statement in this application or willful misrepresentation relative thereto is a violation of federal law, which may subject you to criminal and civil prosecution, 18 U.S.C. Sections 287, 371, 1001; 15 U.S.C. Section 645; 31 U.S.C. Section 231, carrying fines up to $10,000 and imprisonment up to five years.
12. Certification: I hereby certify that all information presented herein is complete and accurate to the best of my knowledge and that the previously submitted, "Statement of Personal History" (SBA Form 912) remains complete and accurate or a revised SBA Form 912 has been submitted.
13. Certification: I hereby certify that I am currently not delinquent on any Federal Debt or federally guaranteed debt.
Signature (Applicant) _____________________________
To be completed by SBA
Date Rec'd by SBA _____________________________
By: (Name) SBG No. _____________________________