Carbon County Industrial Development Authority (CCIDA) and Carbon County Chamber & Economic Development (CCEDC)Small Business Loan Program

Please fill out the information below to the best of your ability.

(To be completed and signed by each officer and major stockholder)

To Download the form, visit: t.ly/kgjqA

This notice to you is provided as required by the “Right to Financial Privacy Act of 1978”. In seeking a loan through one or more of the various Loan Funds administered by the Carbon County Industrial Development Authority (CCIDA) or the Carbon Chamber and Economic Development Corporation (CCEDC) you hereby grant access rights to financial records held by financial institutions that are or have been doing business with you or your business, including financial institutions participating in this loan. Also, you hereby grant CCIDA/CCEDC the right to obtain a credit report through The Jim Thorpe Neighborhood Bank from a credit bureau service relative to your company and personal credit reports on any principals with twenty (20%) percent or more ownership in the company. CCIDA/CCEDC utilizes The Jim Thorpe Neighborhood Bank to conduct credit checks; however, The Jim Thorpe Neighborhood Bank has no interest in the application process or decision on approval of the loan. Access rights continue for the term of any approved loan without further notice or authorization. Under certain Loan Funds, verification of employment and payment of unemployment compensation and worker’s compensation will be made through the Pennsylvania Department of Labor and Industry. This authorizes the CCIDA/CCEDC to use or transfer financial records on an application for an approved loan as necessary to process, service, or foreclose a loan or collect on a defaulted loan. No other transfer of your financial records will be permitted. I/We authorize disclosure of all information submitted in connection with this application to the financial institution agreeing to participate in the loan and to CCIDA members or CCEDC’s Economic Development Committee and to the funding source. I/We give assurance that we will comply with Sections 112 and 113 of Volume 13 of the Code of Federal Regulations. These Code Sections prohibit discrimination on the grounds of race, color, sex, religion, marital status, handicap, age, or national origin by recipients of federal financial assistance and require appropriate report and access to books and records. In addition, I/we give assurance that we will comply with the requirements of Federal and State laws concerning the environment, flood protection insurance if project site is located within a flood plain area, and access for the physically handicapped. These requirements are applicable to anyone who buys or takes control of the business. I/We realize that if I/we do not comply with these requirements, CCIDA/CCEDC can call or, terminate, or accelerate repayment on my/our loan. I/We give assurances that I/we will comply with the provisions of the Americans With Disabilities Act. We understand and agree that no individual with a disability shall on the basis of the disability, be excluded from employment or activities provided for under any loan which CCIDA/CCEDC shall make available under its Loan Funding Program. I/We give assurance that, to the best of my/our knowledge, my/our project has no affect upon historical/archaeological properties and is in compliance with the requirements and objectives of the National Historic Preservation Act of 1966; as amended, Presidential Executive Order 11593, May 13, 1971; and Procedures for the Protection of Historic and Cultural Properties. I/We give assurance that my/our project does not involve relocation as herein defined. Certain CCIDA/CCEDC loan programs capitalized through federal assistance do not allow its funds to be part of any project involving the relocation of an establishment from one area to another causing unemployment at the location where such work was previously performed. For the purposes of this paragraph, “area” means that geographic area which will allow employees of relocated businesses to retain their jobs. Authority to Collect Personal Information -This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974). Effects of Nondisclosure – Omission of an item means your application might not receive full consideration. Agreement of Nonemployment of CCIDA/CCEDC personnel – I/We agree that if CCIDA/CCEDC approves this loan application, I/we will not, for at least two (2) years, hire as an employee or consultant anyone that was employed by the CCIDA/CCEDC during the one-year period prior to the disbursement of the loan. Release and Identification – The undersigned applicant has submitted an application to CCIDA/CCEDC for one or more loans for use in a business either now existing or to be formed or acquired. In conjunction with the consideration of such loan(s) and in furtherance of its mission to provide economic assistance to businesses within its constituent counties, CIDA/CCEDC, may, from time to time, provide advisory services in connection with the formation and operation of the applicant’s business and the means of obtaining appropriate financing for such business. It is expressly acknowledged that CCIDA/CCEDC makes no representation or warranty as to the probability of success of Borrower’s business. It is further acknowledged that CCIDA/CCEDC is under no obligation, either contractual or otherwise, to provide or locate funds needed by the undersigned in either the start-up or operation of the business. Except as expressly set forth in writing, CCIDA/CCEDC makes no commitment that any such funding will be made available. In consideration of consultation, technical, advisory, management services being provided, the undersigned hereby releases and discharges CCIDA/CCEDC from all liability for any loss or damage resulting from the failure of the business, including without limitation, the inability of such business to obtain necessary financing or to meet projections established in any business plan prepared or reviewed by CCIDA/CCEDC. Additionally, the undersigned hereby agrees to indemnify and hold it harmless from all loss or liability which may result from the operation of the said business. All information is true and complete to the best of my/our knowledge. I/We certify that I/we have read this “Notice to Applicants” and that I/we have been given a copy of it.

To Download a PDF of this notice, please click here: t.ly/7sep2