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Application + Instructions

Merchant Cost Forgiveness Advance Program

Effective December 01, 2021

SBA-LynxPayment-MCF-A3058

A BUSINESS OWNER MAY USE THIS FORM ONLY

ELIGIBLE ENTITY VERIFICATION

MERCHANT COST FORGIVENESS ADVANCE

Application Form A3058 Revised December 02, 2021

Control No.: A3508-PL
Expiration Date: 06/16/2022

Purpose of this form:

SBA Lynx Payment is collecting the requested information from the qualified entities listed in this application. The information will be used in determining whether the applicant is eligible for a Merchant Cost Forgiveness Advance (MCF-A3058). If you do not submit all the information requested, your applications cannot be fully processed. All of the information is provided voluntarily by Business Owners to SBA Lynx Payment.

DBA or Tradename if applicable

Business Tax ID (EIN, TIN, SSN)

Business Owner SSN (If applicable)

Applicant Business Phone

Email Address

Business Owner Name

Primary Contact

How long will you stay in the business industry?

MCF Advance Requested Term

Choose One:

Applicant is a business that, together with affiliates, has not more than 300 employees.

Applicant is an individual who operates under a sole proprietorship, with or without employees, or as an independent contractor and, together with affiliates has not more than 300 employees.

Applicant is a cooperative that, together with affiliates, has not more than 300 employees.

Applicant is a tribal small business concern, as described in 15 U.S.C. 657 a(b)(2)(C), that together with affiliates, has not more than 300 employees.

Applicant is a private non-profit organization that is a non-governmental agency or entity that currently has an effective ruling letter from the IRS granting tax exemption under sections 501(c),(d), or (e) of the Internal Revenue Code of 1954, or satisfactory evidence from the State that the non-revenue producing organization or entity is a non-profit one organized or doing business under State l

Applicant is a business that, together with affiliates, has more than 300 employees; and is assigned a NAICS code beginning with 61, 71, 72, 213, 3121, 315, 448, 451, 481, 485, 487, 511, 512, 515, 532 or 812; and employs not more than 300 employees per physical location; and has no more than 20 locations.

Do you request a Fund Advance?

Yes

No

(If yes) Fund Advance Requested Amount

Business Average Monthly Income

Less than $10,000

From $10,000 to $20,000

From $20,000 to $60,000

Over $60,000

Reason for applying Merchant Cost Forgiveness

Current merchant service high rate

Bad customer services

Business License

Upload File

Upload supported file (Max 15MB)

Applicant ID

Upload File

Upload supported file (Max 15MB)

Business Cheque Account

Upload File

Upload supported file (Max 15MB)

Business Start Date (MM/DD/YYYY)

THANK YOU.
The form was submitted successfully.

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