AWG Hearing Request Form (for Santa Ana NDLRC …

U.S. SMALL BUSINESS ADMINISTRATION NATIONAL DISASTER LOAN RESOLUTION CENTER

200 W SANTA ANA BOULEVARD, STE 180 SANTA ANA, CALIFORNIA 92701-4134

AWG Hearing Request Form (for Santa Ana NDLRC-serviced loans only)

For Treasury collection agency-serviced SBA loans, use the form located here.

Borrower Information

Borrower Name: Loan No.:

Instructions To Request a hearing regarding this debt, please check one of the boxes below:

1. Existence of the Debt ? I do not owe the debt 2. Amount of the Debt- I do not owe the full amount of the debt 3. Garnishment amount-I dispute the amount of the proposed garnishment 4. Other (Please explain) REASON: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________

Borrower Contact Information

Mailing Address:

Email : Contact Number:

I declare under the penalty of perjury (18 U.S.C. Section 1001) that the above information is true and correct I understand that if I make or provide any knowingly false or frivolous statements, representations, or evidence to a federal agency, I may be liable for penalties under the False Claims Act (31 U.S.C 3729-3733) or other applicable state laws, statutes, rules, codes, ordinances or regulations.

____________________________ Printed Name

MAIL OR FAX FORM TO: ATTN: LEGAL DEPT US Small Business Administration 200 W. Santa Ana Blvd., Ste 180 Santa Ana, CA 92070 Fax: 714-547-7635

Rev 3-17-15

______________________________ Signature

__________________ Date

Do not use this form if your SBA loan is being serviced by the Treasury Department's collection agency. For SBA loans serviced by the Treasury Department, use the form located here:



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