Arizona SSBCI Technical Assistance Grant Program Form

BUSINESS ELIGIBILITY

Link to NAICS codes

CONTACT INFORMATION

DEMOGRAPHICS FOR PRINCIPAL OWNERS

Please view the Demographic notice and answer the acknowledgement below.

Appendix 2

SSBCI TA Grant Program Form for Demographics-Related Data

The business has received technical assistance under the State Small Business Credit Initiative Technical Assistance Grant Program (SSBCI TA Grant Program), which is a federal program that provides grants to eligible recipients to carry out a techni cal assistance plan to provide legal, accounting, and financial advisory services to small businesses that are applying, have pre viously applied to, or plan to apply to an SSBCI Capital Program or other government program that supports small businesses.

Filling out this form and providing the demographic information requested therein is optional; the business not required to provide the requested information but is encouraged to do so. The entity collecting this information cannot discriminate on the basis of whether an applicant provides the information requested in this form or based on any information provided on this form. If you decline to provide the information requested in this form, it will not adversely affect your ability to receive technical assistance.

The demographics-related information collected can only be used for purposes of the SSBCI TA Grant Program and must not be used for any other purposes (e.g., marketing, sale to third parties). The information collected must also not be used in a manner that violates any applicable anti-discrimination laws, including, but not limited to, the following authorities:

• Title VI of the Civil Rights Act of 1964 (Title VI), 42 U.S.C. § 2000d-1 et seq., and Treasury’s implementing regulations, 31 C.F.R. part 22;
• Section 504 of the Rehabilitation Act of 1973 (Section 504), 29 U.S.C. § 794;
• Title IX of the Education Amendments of 1972 (Title IX), 20 U.S.C. § 1681 et seq., and Treasury’s implementing regulations, 31 C.F.R. part 28;
• the Age Discrimination Act of 1975, 42 U.S.C. § 6101 et seq., and Treasury’s implementing regulations at 31 C.F.R. part 23. If you believe you were discriminated against in connection with the provision of the information provided on this form, con tact: Director, Office of Civil Rights and Equal Economic Opportunity, U.S. Department of the Treasury, 1500 Pennsylvania Ave, N.W., Washington, DC 20220, or by email at [email protected]

This information is being collected to help ensure that communities’ small business technical assistance and access to credit needs are being fulfilled and allow SSBCI to analyze the populations that SSBCI TA Grant Program funding is benefiting.

TECHNICAL ASSISTANCE INFORMATION

Please view the Privacy Notice and answer the acknowledgement below.

Appendix 1

SSBCI Privacy Notice and Privacy Act Statement

Privacy Notice: Information from this collection will be shared with the U.S. Department of the Treasury (Treasury). Treasury will maintain a Privacy and Civil Liberties Impact Assessment that describes what Treasury will do with the information your business provides in connection with the SSBCI TA Grant program. It can be found on the Treasury website. If you have any questions about this document, please email [email protected].

Privacy Act Statement for Sole Proprietorships:

The Privacy Act of 1974 (Privacy Act) protects certain information that the federal government has about “individuals” (United States citizens and lawfully admitted permanent residents). The Privacy Act does not generally apply to businesses, but some federal courts have found that this law applies to sole proprietors (they are deemed “individuals” under the Privacy Act). If you, as the applicant, are a sole proprietor, you may have rights under the Privacy Act.

Authority: Small Business Jobs Act of 2010 (SBJA), Title III, 12 U.S.C. § 5701 et seq., as amended by the American Rescue Plan Act of 2021 (ARPA), section 3301; Executive Order No. 13985, Advancing Racial Equity and Support for Underserved Communities Through the Federal Government, 86 Fed. Reg. 7009 (January 25, 2021); and Interim Final Rule, State Small Business Credit Initiative; Demographics-Related Reporting Requirements, 87 Fed. Reg. 13628 (March 10, 2022).

Purpose: Information from this collection will be shared with Treasury. This information will be shared with Treasury so it can conduct oversight to ensure compliance with the terms and conditions of the SSBCI TA Grant Agreement executed in the re‐ cipient in connection with its TA Grant including federal laws with requirements related to nondiscrimination and nondiscrimi‐ natory uses of federal funds. Treasury also receives this information (including any demographic information provided), to comply with reporting requirements under the authorities listed above, to advance fairness and opportunity in underserved communities in the allocation of federal resources, and to analyze the distribution of resources in federal programs, including to assess program effectiveness and outcomes.

Routine Uses: The information you furnish may be shared in accordance with the routine uses outlined in Treasury .013, Department of the Treasury Civil Rights Complaints, Compliance Reviews, and Fairness in Federal Programs Files System of Records Notice (SORN), 88 Fed. Reg. 12439; Treasury .015, General Information Technology Access Account Records, 85 Fed. Reg. 73353; and Treasury .017, Correspondence and Contact Information, 81 Fed. Reg. 78266. For example, one routine use under Treasury .013 is to disclose pertinent information to appropriate agencies when Treasury becomes aware of a potential violation of civil or criminal law. Under this routine use, Treasury may disclose demographic information to the appropriate agencies if Treasury becomes aware of a violation of applicable antidiscrimination laws. More information about this and other routine uses can be found in the SORNs listed above, updates to which may be periodically noted on Treasury’s website.

Disclosure: Providing this information is voluntary. However, failure to furnish the requested information may result in the de‐ nial of your request to receive SSBCI-supported technical assistance. Providing demographic information is optional. If you de‐ cline to provide this information, it will not adversely affect your eligibility to receive SSBCI-supported technical assistance un‐ der Treasury’s SSBCI TA Grant Program rules and guidance.