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[email protected] ★ www.ccisurety.com ★ 866.317.3294 ph ★ 763.512.0430 fax
CCI Surety, Inc.
1710 N. Douglas Dr., Ste 110
Golden Valley, MN 55422
Application Checklist for the SBA Bond Guarantee Program
1. Questionnaire (attached)
2. Bank reference letter (template attached)
3. SBA Form 912: Statement of Personal History (attached)
4. SBA Form 994: 2nd
and 3rd
pages only (attached) – full document available at www.sba.gov.
Officer must sign at the top on behalf of the company; then ALL owners must sign at the bottom
as individuals. If spouses collectively own 20% or more of the small business, each spouse must
also sign.
5. SBA Form 994F: Work on hand schedule (template attached)
6. Job & Supply References (templates attached) – 3 each
7. Current Certificate of Insurance
8. Personal financials for all owners – must be within 1 year
9. Last three fiscal year-end financial statements
10. Last three year-end tax returns for any affiliated companies (Only the first 2 pages of the return
need to be sent, an officer should sign and date first page)
11. Latest available internal financial statement
If you have a current bid or performance & payment bond request, please send the following:
1. Bond Request Form (attached)
2. Bid Invitation, for bid bonds
3. Copy of the contract and bonds forms, for performance & payment
4. Performance & payment bonds require SBA Fee Payment – Fee is 0.729% of the total contract
value – For Payment and Performance Bonds the attached SBA Authorization Fee Form is
required
Please submit your complete application to Jeremy Crawford via fax or email to
[email protected]. If you have any questions regarding this application or the SBA Program,
please feel free to call CCI Surety, Inc.
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1710 N. Douglas Drive, Golden Valley, Minnesota 55422
Ph: 763-543-6993 Fax: 763-512-0430
CONTRACTOR'S QUESTIONNAIRE FOR SURETY BONDING
Check one: _____Corporation ______Partnership ______Proprietorship ________LLC Date: __________ Telephone: (____)__________ Fax: (_____)___________ Contractor: _______________________________________________________________ (Legal name as registered with the state) Street Address (not P.O.Box): ________________________________________________________ City: ___________________State: ______________Zip: __________County: _________________ Federal Tax ID Number: ____________________Date Business Formed: ______________________ Date Incorporated: __________________ Ownership change in the last five years or are there any plans for change in the corporate ownership or structure? (Please explain) _____________________________________________________________________________________ _____________________________________________________________________________________ What type of construction does the business specialize? (list trades performed by the business) _________ _____________________________________________________________________________________ What percentage of a project does the business perform? _____(%). What trades are typically subbed out? _____________________________________________________________________________________ Are you a union or non-union contractor? ___________________________________________________
OWNERSHIP INFORMATION:
PLEASE LIST SPOUSE AND SSI NUMBER WHETHER OWNER OR NOT:
Name Age Position Ownership (%) SSI# ____________________ ____ ____________________ _____________ ________________ ____________________ ____ ____________________ _____________ ________________ (Spouse) ____________________ ____ ____________________ _____________ ________________ ____________________ ____ ____________________ _____________ ________________ (Spouse)
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KEY PERSONNEL:
Name: Age: Position: Years Employed: Comments: ____________________ ____ ____________________ _____________ ________________ ____________________ ____ ____________________ _____________ ________________ ____________________ ____ ____________________ _____________ ________________ Total Number of Employees: ________________ Number of full time office staff: ______________ Are there any affiliated companies? If so, please explain: _____________________________________________________________________________________
INSURANCE:
Insurance Agency: ____________________________________________________________________ Insurance Agent (name): _____________________________Telephone: (_____)__________________
WORK HISTORY:
(We will call the owners below for reference information) Telephone number Year Completed Contact Person Contract Job
for Reference Amount Description (___ )___________ ______________ _________________ _____________ ____________________ (___ )___________ ______________ _________________ _____________ ____________________ (___ )___________ ______________ _________________ _____________ ____________________ Who was the superintendent on the larger projects? _________________________If they are not employed who replaced them? _______________________________ Normal operating territory? ____________________________________________________________ Largest backlog of work on hand? ($)________________________Number of Projects: _____________ What size projects (single projects) are you looking to Bond? _______________________ Backlog you feel your company needs? ($)_______________#of jobs at one time: _________________
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SUPPLER INFORMATION:
Telephone: Contact Person Product Company Name
(___ )___________ ______________ _________________ _________________________________ (___ )___________ ______________ _________________ _________________________________ (___ )___________ ______________ _________________ _________________________________ • We will contact the above as part of a routine credit check
SURETY INFORMATION:
Present Bond Company? ____________________________________________________________ Bond Agent? _________________________________Telephone: (_____)____________________ Ever caused a bond loss? Yes or No: ___________If so, please explain? _____________________ __________________________________________________________________________________ Bankruptcy personal or business in the last ten years, Yes or No? _______ If yes, please explain? __________________________________________________________________________________
FINANCIAL INFORMATION: Name of accounting firm? ____________________________Telephone: (_____)_______________ Contact Person? _______________________________Used how many years? _________________ Are tax statements for the company current? _________ Personal tax returns current? ____________ Any current Federal Tax liens? _______________If so, please provide details: _________________ _____________________________________Any current State Tax Liens? ________If so, please provide details: _____________________________________________________________________ Any Tax payment plans in place? ______________________________________________________ Who prepares the financial statements in-house for the company and who is in charge of accounts receivable and account's payable? ______________________________________________________
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BANK INFORMATION:
Name of Bank: ____________________________________Contact: ____________________________ Address: ________________________________________________________________________ Telephone: (_____)__________________________Fax: (_____)________________________________ Bank Line Limit: ($)________________________ Amount in Use: _________________ Date: ________
LEGAL REPRESENTATION: Attorney Firm Name: ___________________________________________________________________ Attorney: ___________________________Telephone: (_____)__________Fax: (____)_____________ Any current contract disputes? ____________________________________________________________ Any material or labor liens?_______________________________________________________________ Any lawsuits? _________________________________________________________________________
SBA QUALIFICATIONS: ONLY complete this portion if applying for the SBA Bond Guarantee Program
The Contractor: is is not an SBA 8(a) Certified Contractor is is not an SBA Certified HUB Zone Contractor has has not had an SBA loan. If so, Loan # ________________________________ has has not received SBA Surety Bond Guarantee Assistance under the current or another business name. If so, Business Name __________________________Tax ID or SSN _______________________ has has not defaulted on any previous surety bonds (SBA or other) has has not ever failed to complete a job is is not requesting Business Development Assistance Veteran status of owner(s): _________________________NAICS Code (if known)_______________ Race and ethnicity of owner(s) (i.e. American Indian, African American, Asian, Pacific Islander, White/Caucasian, Hispanic/Latino):________________________________________________________ _____________________________________________________________________________________
CREDIT AUTHORIZATION
We warrant the information contained in this application for Surety Bonding to be true and correct for the assessment of Surety Credit, and authorize Construction Capital, Incorporated to share this information with appropriate Surety Personnel in order to assess Surety Credit. By signing this application, I warrant that I have the authority to release the information contained within this application to Construction Capital, Incorporated. Company: ________________________________________________________________________ By: ______________________________________________________________________ (signature) ___________________________________ Date: _____________________ (name & title)
W11-21-13
1710 N. Douglas Drive
Golden Valley, Minnesota 55422 763-543-6993
763-546-1822 [FAX]
Subject: Financial Institution Bank Letter of Customer Relationship CCI Surety, Inc. has been contacted to assist with the placement of a Surety Bond Program for the firm presenting you with this letter. An important part of the underwriting process is to review our clients relationship with their financial institution, and their past credit performance. A reference letter without exact dollar amounts is of no use. The terminology of a low, medium or high figure is not acceptable for Surety Bond Underwriting. Please provide us with the following: • Date deposit account(s) was opened. • Checking account and savings account 12 month average balance. • Current checking account and savings account balance. • Working capital line information:
-Line Limit -Current balance outstanding, including date of balance -Line expiration date -Security pledged for the line -Any line violations
• Current Loan obligations total of debt, purpose, and its security i.e. equipment etc. -Payment history, prompt etc.
The reference letter should be prepared on bank letterhead, signed, and dated by a Banking Officer. If there are any questions, please feel free to contact our office at either 763-543-6993 or 1-866-317-3294. Sincerely, CCI Surety, Inc.
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United States of America
SMALL BUSINESS ADMINISTRATION
STATEMENT OF PERSONAL HISTORY
OMB APPROVAL NO.3245-0178Expiration Date:
Please Read Carefully: � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � ! � � � � � � � �� � � " � � � � � � # � � $ � � % & ' ' % ( % � � ) % � � � * � % & ' ' % & � + % , + � � - ! � � � � � � $ � � � " � � � � � � � � � � � � � � � � . / 0 / 1 2 3 0 . 4 / 5 6 7 3 1 3 . 8 / 9 5 2 1 / / 5 : ; <= > ? < @ ? A A B C A ; D = > C E F G H C < < ? I J G K D G L F ; E E A ? H ; = ? G I M < C I B K G F N < = G = > C ; B B F C < <E F G O ? B C B P D D G L F A C I B C F G F 2 : Q F C E F C < C I = ; = ? O C R
Name and Address of Applicant (Firm Name)(Street, City, State, and ZIP Code) SBA District/Disaster Area Office
Amount Applied for (when applicable) File No. (if known)
1. Personal Statement of: (State name in full, if no middle name, state (NMN), or if initialonly, indicate initial.) List all former names used, and dates each name was used. Use separate sheet if necessary.
First Middle Last
2. Give the percentage of ownership or stock owned
3. Date of Birth (Month, day, and year)
4. Place of Birth: (City & State or Foreign Country)
U.S. Citizen? YES NO
If non- U.S. citizen provide alien registration number:
Address:
Present residence address:
From:
To:
Home Telephone No. (Include Area Code):
Business Telephone No. (Include Area Code):
Address:
Most recent prior address (omit if over 10 years ago):
From:
To:
PLEASE SEE REVERSE SIDE FOR EXPLANATION REGARDING DISCLOSURE OF INFORMATION AND THE USES OF SUCH INFORMATION.
YOU MUST INITIAL YOUR RESPONSES TO QUESTIONS 5,7,8 AND 9.
IF YOU ANSWER "YES" TO 7, 8, OR 9, FURNISH DETAILS ON A SEPARATE SHEET. INCLUDE DATES, LOCATION, FINES, SENTENCES, WHETHERMISDEMEANOR OR FELONY, DATES OF PAROLE/PROBATION, UNPAID FINES OR PENALTIES, NAME(S) UNDER WHICH CHARGED, AND ANYOTHER PERTINENT INFORMATION. AN ARREST OR CONVICTION RECORD WILL NOT NECESSARILY DISQUALIFY YOU; HOWEVER, AN
7. Are you presently subject to an indictment, criminal information, arraignment, or other means by which formal criminal charges are brought in any jurisdiction?
Yes No
8. Have you been arrested in the past six months for any criminal offense?
Yes No
9. For any criminal offense – other than a minor vehicle violation – have you ever: 1) been convicted; 2) plead guilty; 3) plead nolo contendere; 4) been placed on pretrial diversion; or 5) been placed on any form of parole or probation (including probation before judgment).
Yes No
10. I authorize the Small Business Administration Office of Inspector General to request criminal record information about me from criminal justice agencies for the purpose ofdetermining my eligibility for programs authorized by the Small Business Act, and the Small Business Investment Act.
CAUTION - PENALTIES FOR FALSE STATEMENTS: Knowingly making a false statement on this form is a violation of Federal law and could result in criminal prosecution, significant civil penalties, and a denial of your loan, surety bond, or other program participation. A false statement is punishable under 18 USC 1001 and 3571 by imprisonment of not more than five years and/or a fine of up to $250,000; under 15 USC 645 by imprisonment of not more than two years and/or a fine of not more than $5,000; and, if submitted to a Federally insured institution, under 18 USC 1014 by imprisonment of not more than thirty years and/or a fine of not more than $1,000,000.
Signature Title Date
Agency Use Only
Fingerprints WaivedDate Approving Authority
Fingerprints Required
Date Sent to OIGDate Approving Authority
11.Cleared for Processing
Request a Character EvaluationApproving Authority
12.
SBA 912 (2-2013) SOP 5010.4 Previous Edition Obsolete
PLEASE NOTE: The estimated burden for completing this form is 15 minutes per response. You are not required to respond to any collection of information unless it displays a currently valid OMBapproval number. Comments on the burden should be sent to U.S. Small Business Administration, Chief, AIB, 409 3rd St., S.W.,Washington D.C. 20416 and Desk Officer for the Small BusinessAdministration, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503. OMB Approval 3245-0178.
Social Security No.
or to be owned in the small business or thedevelopment company
Name and Address of participating lender or surety co. (when applicable and known)
If No, are you a LawfulPermanent resident alien:
YES NO
6.
5.
13.
(Required whenever 7, 8 or 9 are answered "yes" even if cleared for processing.)
Date
Date Approving Authority
INITIALS:
INITIALS:
INITIALS:
INITIALS:
UNTRUTHFUL ANSWER WILL CAUSE YOUR APPLICATION TO BE DENIED AND SUBJECT YOU TO OTHER PENALTIES AS NOTED BELOW.
DO NOT SEND COMPLETED FORMS TO OMB as this will delay the processing of your application; send forms to the address provided by your lender or SBA representative.
04/30/2016
W11-21-13
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Applicant business has attempted and failed to obtain the required bonds without SBA’s guarantee.c C d 9 M M N E C G > ? E @ > D ? F < N E > Q R < > ? D > G > O W < F < ; G N F < b ? D ; W < F < ; G N N O f R G ; G > ? < < F g < b ? ac F d 9 N N E > H D ; = G ? E D > E > ? I E @ G M M N E C G ? E D > G > F ? I G ? ; < N G ? < @ ? D ? I E @ G M M N E C G ? E D > P I E C I I G @ b < < > @ R b = E ? ? < F ? D J K 9 L G > O G : < > ? L b ; D h < ; L D ; @ R ; < ? O C D = M G > O L E @ C D = M N < ? < G > FG C C R ; G ? < ? D ? I < b < @ ? D H = O h > D P N < F : < ac < dIf Parts I, II and V of this application, and/or “Statement of Personal History” (SBA Form 912) have previously been submitte
F E > C D > > < C ? E D > P E ? I G > < G ; N E < ;G M M N E C G ? E D > L B I G \ < ; < \ E < P < F ? I G ? E > H D ; = G ? E D > G > F C < ; ? E H O ? I G ? E ? < E ? I < ; ; < = G E > @ C D = M N < ? < G > F G C C R ; G ? < D ; ? I G ? B I G \ < @ R b = E ? ? < F G ; < \ E @ < F G M M N E C G ? E D > Y G ; ? @ B L B B D ; iD ; ; < \ E @ < F J K 9 W D ; = j T ^ P E ? I C D = M N < ? < G > F G C C R ; G ? < E > H D ; = G ? E D > ? D ? I < b < @ ? D H = O h > D P N < F : < ac H d 9 > O G : < > ? L b ; D h < ; L J R ; < ? O V D = M G > O L H E > G > C E G N E > @ ? E ? R ? E D > L D ; D ? I < ; M G ; ? O E > M D @ @ < @ @ E D > D H C ; < F E ? L H E > G > C E G N D ; P D ; h < [ M < ; E < > C < E > H D ; = G ? E D > C D > C < ; > E > : ? I <undersigned applicant and the applicant’s business
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¡ ¢ £ ¤ ¥: CERTIFICATION WITH RESPECT TO “STATEMENTS ¦ § ¨ © ª ¦ § « ¬ ® ¯ ° ¯ ± « § ² § ³ © ´ ª ¥ § µ ¦ « § ¦ ”¯ ± « « § ¬ ¯ ¦ ¶ § ± ´ · ¸ © ¸ ¡ § ± ¸ ª µ ± · ª ± § ® ª ¹ ª ¬ ª ® ª ´ ¯ ± « ¥ µ ® © ± ´ ¯ ¦ § ² ³ ® © ¸ ª µ ± º ´ » ¼ ½ ¡ ¢ £ ¤ ¤ ¾ ¿ À Á ¾ Â Ã Ä À ¤ À Å ¿ Ƹ  ¢ Ä Ä ¬ Ç ½ ¼ È À ½ ½ É ¾ £ ª È ¼ ¤ ¼ ¢ Ä ¯ Ã Ã Ä ¼ Á ¢ ¤ ¼ ¾ È ¢ È Å Ç Ã Å ¢ ¤ À Å ¢ È Å ½ Ç ¿  ¼ ¤ ¤ À Å ¤ ¾ ¸ ¬ ¯ Ê » À È ¤ » À £ À ¢ £ À ¢ È Æ µ Ê È À £ ½ » ¼ à ³ » ¢ È Ë À ½ ̳ À £ ¤ ¼ É ¼ Á ¢ ¤ ¼ ¾ È ¾ È ¬ À » ¢ Ä É ¾ É ¤ » À ¸  ¢ Ä Ä ¬ Ç ½ ¼ È À ½ ½ Í
By my signature, I certify, on behalf of the small business, that I have received and read a copy of the “STATEMENTS REQUIRED Î Ï Ð Ñ Ò Ñ Ó ÔEXECUTIVE ORDER” (StateÕ Ö × Ø Ù Ú Û Ü Ý Þ Ü Û ß à ß Ø Ø ß Þ Ü Ö á Ø â Ø Ü Ý à Ñ ã ã ä Ý Þ ß Ø Ý â × Ú ß × á å ß æ ç Ö Ö Ø â Þ â Õ ã ä è Û Ý Ø Ü Ø Ü Ö ç Ö é ê Ý ç Ö Õ Ö × Ø à Ý × Ø Ü Ö ë Ø ß Ø Ö Õ Ö × Ø ì å ß ä à âÞ Ö ç Ø Ý í è Ø Ü ß Ø å ß Õ ß ê Ø Ü â ç Ý î Ö á Ø â Ö ï Ö Þ ê Ø Ö Ø Ü Ý à Þ Ö ç Ø Ý í Ý Þ ß Ø Ý â × â × ð Ö Ü ß ä í â í Ø Ü Ö à Õ ß ä ä ð ê à Ý × Ö à à ì å ê × á Ö ç à Ø ß × á Ø Ü ß Ø ñ × â Û Ý × æ ä è Õ ß ñ Ý × æ ß í ß ä à Ö à Ø ß Ø Ö Õ Ö × Ø â çà ê ð Õ Ý Ø Ø Ý × æ í ß ä à Ö Ý × í â ç Õ ß Ø Ý â × Ý à ß ò Ý â ä ß Ø Ý â × â í ó Ö á Ö ç ß ä ä ß Û ß × á Þ â ê ä á ç Ö à ê ä Ø Ý × Þ ç Ý Õ Ý × ß ä ã ç â à Ö Þ ê Ø Ý â × â ç Þ Ý ò Ý ä ã Ö × ß ä Ø Ý Ö à ê × á Ö ç ô õ ö ì ë ì ÷ ì ø ù õ ú Ú û ú ô Ú ô ü ü ô Úô ý ö ì ë ì ÷ ì ø þ ÿ ý Ú â ç û ô ö ì ë ì ÷ ì ø û ú ù � ìÎ ê à Ý × Ö à à Ó ß Õ Ö � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Î è � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �
Principal’s Signature/Title Ô ß Ø Öl n o y � y o m t { � p q s y ~ y � t s y w n r �� t � u � q w � q y p s w q � p t � u � p n p q t { � t q s n p q � p t � u � m t q t n s w q � t n o p t � u � y } y s p o � t q s n p q � � s w � v u w { o p q � w q w s u p q p � m y s | u w { o p q w x n y n z � � � w q } w q pw ~ s u p r } t { { � m r y n p r r } m r s r y z n � � u p � p q r w n r y z n y n z w n � p u t { ~ w ~ s u p � m r y n p r r } m r s t { r w r y z n y n o y � y o m t { { | � l n t o o y s y w n � y ~ r � w m r p r � w { { p � s y � p { |w x n � � � w q } w q p w ~ s u p r } t { { � m r y n p r r � p t � u r � w m r p } m r s t { r w r y z n �� | } | r y z n t s m q p � l � p q s y ~ | s u t sI have received and read a copy of the “STATEMENTS REQUIRED BY LAW AND EXECUTIVE ORDER” � � s t s p } p n s r � � x u y � u x t r t s s t � u p o s w s u y r � � � { y � t s y w n � t n o l t z q p p s w � w } � { | x y s u s u p q p � m y q p } p n s r y n s u p � s t s p } p n s � l t { r w � p q s y ~ | s u t s l u t � pq p � y p x p o s u p y n ~ w q } t s y w n y n � t q s � w ~ s u y r ~ w q } t n o � p q s y ~ | s u t s t r s w } p � p q r w n t { { | t { { y n ~ w q } t s y w n y n s u y r � � � { y � t s y w n y r t � � m q t s p t n o� w } � { p s p s w s u p � p r s w ~ } | v n w x { p o z p � l m n o p q r s t n o s u t s v n w x y n z { | } t v y n z t ~ t { r p r s t s p } p n s w q r m � } y s s y n z ~ t { r p y n ~ w q } t s y w n y r t � y w { t s y w n w ~� p o p q t { { t x t n o � w m { o q p r m { s y n � q y } y n t { � q w r p � m s y w n w q � y � y { � p n t { s y p r m n o p q � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � w q � � � � � � � � � � � � � �� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �J E : > G ? R ; < G > F S E ? N < g G ? <� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �J E : > G ? R ; < G > F S E ? N < g G ? <� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �J E : > G ? R ; < G > F S E ? N < g G ? <� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �J E : > G ? R ; < G > F S E ? N < g G ? <� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �J E : > G ? R ; < G > F S E ? N < g G ? <� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �J E : > G ? R ; < G > F S E ? N < g G ? <� � � � w q } � � � � � � � � � � q p � y w m r � o y s y w n r t q p � � r w { p s p
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OMB Control No: 3245-0007 Expiration Date: 02/16/2016
Instructions: The small business must complete this form and submit it, either electronically or on paper, to the surety agent of choice. A list of participating surety agencies and the paper version is available on the Office of Surety Guarantees website at www.sba.gov/osg. If the application is submitted electronically, the pre-populated form can be printed from the E-App system.
SMALL BUSINESS ADMINSTRATION SCHEDULE OF WORK IN PROCESS (ALL WORK-BONDED & UNBONDED-IF COST PLUS PLEASE INDICATE)
BUSINESS NAME AND BUSINESS TRADE NAME TAX ID OR SS NUMBER DATE AS OF
JOB DESCRIPTION
STARTING DATE
COMPLETION DATE
BONDED YES / NO
CONTRACT PRICE (Including Approved
Change Orders)
Total Billed to Date Including Retainages (Explain Any Dispute
Items)
Total Cost To Date
Total Estimated Cost To Complete
1 2 3 4 5 6 7 8 9
10 11 12 13 14 15
TOTALS Signature Title PLEASE NOTE: The estimated burden for completing this form is 20 minutes per response. You are not required to respond to any collection of information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to: Chief, Administrative Information Branch, Room 5000, U.S. Small Business Administration, 409 3rd St., SW. Washington, DC 20416; and Desk Officer for the Small Business Administration, Office of Management and Budget, New Executive Office Building, Room 10202 Washington, DC 20503.
SBA Form 994F (1/13) Previous Editions are Obsolete
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1710 N. Douglas Dr., Suite 110 Golden Valley, MN 55422 (763) 543-6993 Fax (763) 546-1822
BOND REQUEST FORM
Date Ordered: ______________ Requested By: _______________________ Principal / Contractor: _____________________________________________________ Obligee / Owner: _________________________________________________________ (to whom bond is payable to)
Obligee Address: _________________________________________________________
Obligee Contact Person:____________________________________________________
Phone Number:___________________________________________________________ Bid Date and Time: _____________________ Amount of Bid: $__________________ Bid Bond % or $:______ Performance %:_______ Payment %:_______ Other:________ Contract Date: ________ Contract Amount: ____________ Bond Amount: ___________ Description & Project / Contract No.: _________________________________________ _______________________________________________________________________ ___________________________________________ Location of Work: _____________ Estimated Start Date: _____________ Estimated Completion Date: _________________ Liquidated Damages / Penalties: __________ Warranty Length / Period: _____________ Labor % ______ Material % _______ Gross Profit % _______ Subbed % ___________ Subcontracted Trades Approx. Dollar Amount Bonded? ________________________ __________________ ________ ________________________ __________________ ________ ________________________ __________________ ________ ________________________ __________________ ________ ________________________ __________________ ________ Bid Results (dollar amount): #1$___________#2______________#3________________ Cost to Complete Work in Progress: $_________ Available Bank Credit: $___________ Bond Form (check one): Standard Form ( ) Federal ( ) State ( ) AIA ( ) #_______
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Electronic SBA Fee Authorization Form Contractor’s Name: . Address: .
Obligee’s Name: . Contract Amount: .
I/We hereby authorize CCI Surety, Inc. to enter my credit card/checking account information into www.pay.gov for my
SBA Fee in the amount of $ .
*Please check only one option for payment below (Credit Card or Checking/Savings):
Credit Card Payment
Credit Card Type (Check One): VISA Mastercard Discover Amex
Credit Card #: Exp. Date: CVV: . (3 digit number on back of card)
Cardholder Name (as it appears on the card): .
Billing Address: .
City: State: Zip: . Checking/Savings Payment *Please fill out the bottom portion OR attach a voided check*
Account Type (Check One): Checking Savings
Name on Account: .
Bank Name: .
Account #: .
Bank Routing #: .
Bank City/State: .B I agree to pay the total amount listed above. I certify that the above statements and information made in the agreement are true and correct to the best of my knowledge. I also certify that I am authorized to effect charges to the above credit card and/or account number. I agree to notify CCI Surety, Inc. in writing of any changes in my credit card and/or account information immediately. This authority is to remain in full force and effect until the payment has been made in full according to the amount listed above by CCI Surety, Inc.
Print Name: .
Signature: Date: .
Florida Office 1408 N. Westshore Blvd
Suite 120Tampa, FL 33607
Phone 813-443-2174 Fax 813-443-2176
Toll Free 1-877-320-6947
Home Office 1710 N. Douglas Dr.
Suite 110 Golden Valley, MN 55422
Phone 763-543-6993 Fax 763-512-0430
Toll Free 1-866-317-3294
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