National Ombudsman Case Management System

Federal Agency Comment Form

Federal Agency Comment Form

Small Business Administration - Office of the National Ombudsman

PURPOSE: Small business owners may use this form to submit comments on Federal enforcement/compliance actions that they consider excessive or unfair. The National Ombudsman will use the information when it contacts the applicable Federal agency for a review of the action. Completion of this form is voluntary; however, failure to submit the requested information could impact whether SBA’s Office of the National Ombudsman is able to provide you with assistance.

OMB Control #3245-0313
Exp. date 8/31/2025
Case #:

Instructions

1. Complete, sign, and date this form. A signature is not required for web submissions.

2. Provide a brief statement on the specific enforcement action / compliance assistance / communication to your small entity by a federal agency.

3. Submit substantiating documentation (for example: the correspondence, notice, or fine). If this is provided separately by email, fax, or mail, please reference the name of your small entity.

4. If your comment concerns the IRS, you must also submit a completed IRS Tax Information Authorization (Form 8821). This is available at IRS.gov/forms

5. Email this form and relevant documentation to Ombudsman@SBA.gov

Type of Small Entity:

Was your small entity debanked?

List the bank (if applicable):

Reason:

Company / Organization Name:

Country:

Zip/Zip+4:

(Please Use Lookup Zip to auto populate City Name and State)

Street Address 1:

Street Address 2:

City Name:

(State)

Phone:

(999-999-9999)

Fax:

(999-999-9999)

Email:

Contact Name:

Prefix

( First )

(Middle)

(Last)

Title:

Relevant Federal Agency Name:

Applicable Regulation (if known):

Confidentiality / Disclosure
Per the Small Business Regulatory Enforcement Fairness Act, the Office of the National Ombudsman (ONO) will keep confidential the identities of small entities filing Federal Agency Comments (“Comments”). Commenters may authorize ONO to share their identity with the relevant SBA office(s) and / or federal agency(ies) to provide a resolution.

I authorize ONO to share my identity with the relevant SBA office(s) and/or federal agency(ies) in response to this comment.

I request my identity be kept confidential.

Signature:

Date:

Your signature authorizes the SBA Ombudsman to proceed on your behalf

Pursue all legal options you believe are in your company's best interest. This process is not a substitute for legal action.

SBA FORM 1993 (9-22) Previous Editions Obsolete
PLEASE NOTE: The estimated burden for completing this form is 45 minutes. You are not required to respond to this information collection if a valid OMB approval number is not displayed. If you have any questions or comments concerning this estimate or other aspects of this information collection, please contact the U. S. Small Business Administration, Director, Records Management Division, 409 Third Street, SW, Washington, D.C., 20416 and/or Office of Management and Budget, SBA Desk Officer, New Executive Office Building, Rm. 10202, Washington, D.C. 20503. PLEASE DO NOT SEND FORMS TO OMB, as this will delay action on your request for assistance.

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