BY SIGNING, I REQUEST SERVICES FROM ECDI, A SMALL BUSINESS ADMINISTRATION (SBA) RESOURCE PARTNER:
I understand information disclosed will be held in strict confidence; ECDI/SBA will not provide personal information to commercial entities.
I agree to participate in program surveys that evaluate ECDI/SBA services. I authorize ECDI/SBA to furnish relevant information to assigned staff.
I understand the advising staff will not:
- Recommend goods or services from sources he/she has an interest in or
- Accept fees or commissions developing from this advising relationship. In consideration of management or technical assistance provided, I waive all claims against EF/SBA and its resource partners and host organizations arising from this assistance.
Information provided is used to report to funders, many who require that the ECDI serve specific populations. I understand for some programs and services, I will need to furnish ECDI with personal, household and business income to satisfy funder requirements. I certify that information regarding my income is accurate and complete. I authorize ECDI to verify the income information provided and share with funders for reporting purposes.
Warning (SBA): Section 1001 of Title 18 of the United States Code (Criminal Code and Criminal Procedure) shall apply to the foregoing certification. Title 18, provides among other things, that whoever, knowingly and willingly makes or uses a document or writing containing any false, fictitious or fraudulent statement or entry, in any manner within the jurisdiction of any department or agency of the United States, shall be fined not more than $10,000 or imprisoned not more than five years, or both.
Note: The estimated burden for completing this form is 18 minutes. You are not required to respond to any collection information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to: US Small Business Administration, 409 3rd St, SW, Washington, DC 20416, and to: Desk Officer SBA, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, DC, 20503. OMB Approval (3245-0324). PLEASE DO NOT SEND FORMS TO OMB.