Paycheck Protection Program ~ OMB Control Number 3245-0407
Loan Forgiveness Application Revised June 16, 2020 Expiration Date: 10/31/2020
PPP Loan Forgi Calculation F
Business Legal Name (“Borrower”) DBA or Tradename, if applicable
TmiEN gf wes Tadic, Death denalhy Tne, _
Business Address Business TIN (EIN, SSN) Business Phone
22. Bex [2221 SH-[66 pag \ISFO-7IP
ich y) Ye Primary Contact E-mail Address.
Z 7
Richmond) ZO2LY/ Michse) Stone, \#ice@, lagonat
SBA PPP Loan Number; /B2, =O Lender PPP Loan Number: 20992 4/2,
<=
PPP Loan Amount: f2), SEL, 52 PPP Loan Disbursement Date: O22 —2¢47
4
Employees at Time of Loan Application: _A-~ Employees at Time of Forgiveness Application: Zz.
EIDL Advance Amount: ZB 2,200.20 EIDL Application Number: _320/2G3ZZ O
Payroll Schedule: The frequency with which payroll is paid to employees is:
0 Weekly MW Biweekly (every other week) 0 Twice a month O Monthly O Other _
2 -fy7
Covered Period: 2022-2 -/2 9 PREBLE 2ojyp-/0-O2, HEL
Alternative Payroll Covered Period, if i to
If Borrower (together with affiliates, if applicable) received PPP loans in excess of $2 million, check here:
Forgiveness Amount Calculation:
payroll Costs $
Payroll and Non
Line |. Payroll Costs (enter the amount from PPP Schedule A, line 10):
Line 2. Business Mortgage Interest Payments: Z
Line 3. Business Rent or Lease Payments: A]
C
Line 4. Business Utility Payments: D _
c
dd for Full-Time Equival (ETE) and Salary/Hourly Wage Reduction PES
Line 5. Total Salary/Hourly Wage Reduction (enter the amount from PPP Schedule A, line 3): _
97. MES
Line 6. Add the amounts on lines 1, 2, 3, and 4, then subtract the amount entered in line 5:
Line 7. FTE Reduction Quotient (enter the number from PPP Schedule A, line 13): _ 40
Potential Forgiveness Amounts.
Line 8. Modified Total (multiply line 6 by line 7): 2), 022.
Line 9. PPP Loan Amount: Ll, G22.00
Line 10. Payroll Cost 60% Requirement (divide line | by 0.60): 33,176.02
Forgiveness Amount a
Line 1. Forgiveness Amount (enter the smallest of lines 8, 9, and 10): £ A SG, Se
SBA Form 3508 (06/20)
Page |
Paycheck Protection Program « OMB Control Number 3245-0407
Loan Forgiveness Application Revised June 16, 2020 Expiration Date: 10/31/2020
By Signing Below, You Make the Following Repr ions and Certifications on Behalf of the Borrower:
The authorized representative of the Borrower certifies to all of the below by initialing next to cach one.
ES — The dollar amount for which forgiveness is requested:
* — was used to pay costs that are eligible for forgiveness (payroll costs to retain employees; business mortgage interest
payments; business rent or lease payments; or business utility payments);
¢ includes all i ducti due to decreases in the number of full-time equivalent employees and
salary/hourly wage reductions;
¢ — includes payroll costs equal to at least 60% of the forgiveness amount;
¢ if 24-week Covered Period applies, does not exceed 2.5 months’ worth of 2019 compensation for any owner-
employee or self-employed individual/general partner, capped at $20,833 per individual; and
¢ if the Borrower has elected an 8-week Covered Period, does not exceed 8 weeks’ worth of 2019 compensation for
any owner-employee or self-employed individual/general partner, capped at $15,385 per individual.
MES T understand that if the funds were knowingly used for unauthorized purposes, the federal government may pursue recovery
of loan amounts and/or civil or criminal fraud charges.
MES The Borrower has accurately verified the payments for the eligible payroll and nonpayroll costs for which the Borrower is
requesting forgiveness.
MGS {have submitted to the Lender the required documentation verifying payroll costs, the existence of obligations and service
(as applicable) prior to February 15, 2020, and eligible business mortgage interest payments, business rent or lease
payments, and business utility payments.
MEL The information provided in this application and the information provided in all supporting documents and forms is true
and correct in all material respects. I understand that knowingly making a false statement to obtain forgiveness of an
SBA-guaranteed loan is punishable under the law, including 18 U.S.C. 1001 and 3571 by imprisonment of not more than
five years and/or a fine of up to $250,000; under 15 U.S.C. 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 U.S.C. 1014 by imprisonment of not
more than thirty years and/or a fine of not more than $1,000,000.
7025 The tax documents I have submitted to the Lender are consistent with those the Borrower has submitted/will submit
to the IRS and/or state tax or workforce agency. I also understand, acknowledge, and agree that the Lender can share
the tax information with SBA’s authorized representatives, including authorized representatives of the SBA Office of
Inspector General, for the purpose of ensuring compliance with PPP requirements and all SBA reviews.
MES 1 understand, acknowledge, and agree that SBA may request additional information for the purposes of evaluating the
Borrower's eligibility for the PPP loan and for loan forgiveness, and that the Borrower's failure to provide information
requested by SBA may result in a determination that the Borrower was ineligible for the PPP loan or a denial of the
Borrower's loan forgiveness application.
MES If the Borrower has checked the box for FTE Reduction Safe Harbor | on PPP Schedule A, the Borrower was unable
to operate between February 15, 2020 and the end of the Covered Period at the same level of business activity as
before February 15, 2020 due to pl with r blished or guidance issued between March 1, 2020
and December 31, 2020, by the Secretary of Health and Human Services, the Director of the Centers for Disease Control
and Prevention, or the Occupational Safety and Health Administration, related to the maintenance of standards of sanitation,
social distancing, or any other work or customer safety requirement related to COVID-19
The Borrower's eligibility for loan forgiveness will be evaluated in accordance with the PPP regulations and guidance issued by SBA
through the date of this application. SBA may direct a lender to disapprove the Borrower's loan forgiveness application if SBA
determines that the Borrower was ineligible for the PPP loan.
ignafureorAuthofized Representative of Borrower i
a) "
Liichad B. Sone Execitile Ditestoy
Print Name’ Title
SBA Form 3508 (06/20)
Page 2
Paycheck Protection Program® OMB Control Number 3245-0407
a Loan Forgiveness Application Revised June 16, 2020 Expiration Date: 10/31/2020
PPP Schedule A.
Line 1. Enter Cash Compensation (Box 1) from PPP Schedule A Worksheet, Table I: 07,50
Line 2. Enter Average FTE (Box 2) from PPP Schedule A Worksheet, Table |: —— 41D
Line 3. Enter Salary/Hourly Wage Reduction (Box 3) from PPP Schedule A Worksheet, Table |: ——
If the average annual salary or hourly wage for each employee listed on the PPP
Schedule A Worksheet, Table | during the Covered Period or the Alternative Payroll
Covered Period was at least 75% of such employee’s average annual salary or hourly
wage between January |, 2020 and March 31, 2020, check here and enter 0 on line 3
PPP Schedule A Worksheet, Table 2 Totals
Line 4. Enter Cash Compensation (Box 4) from PPP Schedule A Worksheet, Table 2: ee os
Line 5. Enter Average FTE (Box 5) from PPP Schedule A Worksheet, Table 2: _ go =
Non-Cash C. sation Payroll Costs During the Covered Period or the Alternative Payroll Covered Period
Line 6. Total amount paid or incurred by Borrower for employer contributions for employee heatthinsurance:
Line 7. Total amount paid or incurred by Borrower for employer contributions to employee retirementplans: =
Line 8. Total amount paid or incurred by Borrower for employer state and local taxes assessed on employee
compensation: ow
7
Compensation to Owners
Line 9. Total amount paid to owner-employees/self-employed individual | partners: 2
This amount may not be included in PPP Schedule A Worksheet, Table | or 2. If there is
more than one individual included, attach a separate table that lists the names of and
payments to each.
Total Payroll Costs
Line 10, Payroll Costs (add lines 1, 4, 6, 7, 8, and 9): # 2 f07. 52
Full Equival (FTE) Reduction Calcul:
If you satisfy any of the following three criteria, check the appropriate box, skip lines 11 and 12, and enter 1.0 on line 13; otherwise,
complete lines 11, 12, and 13:
No reduction in employees or average paid hours: If you have not reduced the number of employees or the average paid hours of
your employees between January 1, 2020 and the end of the Covered Period, check here O.
FTE Reduction Safe Harbor 1: If you were unable to operate between February 15, 2020, and the end of the Covered Period at the
same level of business activity as before February 15, 2020 due to Lit with requi stablished or guidance issued
between March 1, 2020 and December 31. 2020, by the Secretary of Health and Human Services, the Director of the Centers for Disease
Control and Prevention, or the Occupational Safety and Health Administration related to the mai of for sanitation
Social distancing, or any other worker or customer safety requirement related to COVID-19, check here 0.
: ‘4
FTE Reduction Safe Harbor 2: If you satisfy FTE Reduction Safe Harbor 2 (see PPP Schedule A Worksheet), check tener yes
Line 11. Average FTE during the Borrower’s chosen reference period:
Line 12. Total Average FTE (add lines 2 and 5):
Line 13. FTE Reduction Quotient (divide line 12 by line 11) or enter 1.0 if any of the above criteria ee ae
SBA Form 3508 (06/20)
Page 3
Paycheck Protection Program « OMB Control Number 3245-0407
Loan Forgiveness Application Revised June 16, 2020 Expiration Date: 10/31/2020
PPP Schedule A Worksheet
Table 1: List employees who:
« Were employed by the Borrower at any point during the Covered Period or the Alternative Payroll Covered Period whose
principal place of residence is in the United States; and
e Received compensation from the Borrower at an annualized rate of less than or equal to $100,000 for all pay periods in
2019 or were not employed by the Borrower at any point in 2019.
Employee Salary / Hourly Wage
Employee's Name ifier_| Cash Compensation] Average FTE Reduction
Michae) Stone fo |73.676. T¥ LO B 977.7
Dale Bram$ic JA F2 4 230. TK LO DZ
£ OF 52 1D.
FTE Reduction Exceptions: Qed?
Totals: [Box 1 Box 2 Box 3
Table 2: List employees who:
© Were employed by the Borrower at any point during the Covered Period or the Alternative Payroll Covered Period whose
principal place of residence is in the United States; and
« Received compensation from the Borrower at an annualized rate of more than $100,000 for any pay period in 2019.
Employee
Employee's Name Identifier | Cash Compensation] Average FTE
UR Miz DO.
Totals: Box 4 Box 5
Attach additional tables if additional rows are needed.
FETE Reduction Safe Harbor 2:
Step 1. Enter the borrower’s total average FTE between February 15, 2020 and April 26, 2020. Follow the same method that
was used gyaeuas Average FTE in the PPP Schedule A Worksheet Tables. Sum across all employees and enter
Step 2. Enter the borrower's total FTE in the Borrower's pay period inclusive of February 15, 2020. Follow the same method
rd
that was used in step 1
Step 3. If the entry for step 2 is greater than step 1, proceed to step 4. Otherwise, FTE Reduction Safe Harbor 2 is not
applicable and the Borrower must complete line 13 of PPP Schedule A by dividing line 12 by line 11 of that schedule
Step 4. Enter the borrower's total FTE as of the earlier of December 31, 2020, and the date this application is submitted: A?
Step 5. If the entry for step 4 is greater than or equal to step 2, enter 1.0 on line 13 of PPP Schedule A; the FTE Reduction Safe
Harbor 2 has been satisfied. Otherwise, FTE Reduction Safe Harbor 2 does not apply and the Borrower must complete
line 13 of PPP Schedule A by dividing line 12 by line 11 of that schedule.
SBA Form 3508 (06/20)
Page 4
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