Federal Agency Comment Form

OMB Control #3245-0313

Small Business Administration - Office of the National Ombudsman

Exp. date 6/30/2010

409 Third Street SW, Washington, DC 20024

P: (202) 205-2417 - F: (202) 481-5719

Instructions

1. Complete, sign and date this form. (Signature not required if completed at www.sba.gov/ombudsman).

2. Provide a brief written statement on the reverse side regarding the specific enforcement or compliance action taken against your organization by the federal agency.

3. Submit copies of substantiating documentation, such as correspondence, citation, or notice (Note: Can be submitted separately from this form by fax or mail. Make sure to reference your name or company's name with this information).

4. If your comments concern the IRS, you must also submit a completed IRS Tax Information Authorization Form 8821, available at http://www.irs.gov/forms (Can be sent by fax or mail).

5. Fax, email or send this form and requested information to: (1) Fax: (202) 481-5719; (2) E-mail: Ombudsman@sba.gov (3) Address: SBA, Office of the National Ombudsman, 409 Third Street, SW, Washington, DC 20024.

Organization/Company Name:

Country:

Zip/Zip+4:

Street 1:

Street 2:

City Name:

(State)

Phone:

(999-999-9999)

Fax:

(999-999-9999)

Name:

(First)

(Middle)

(Last)

Title:

Email:

No.of Members Representing:

Organization Type:

List the federal agency with which you are having a problem

Federal Agency Name:

Agency Contact person:

Agency Office/Division:

Did the federal agency listed above inform you of your right to contact the SBA Office of the National Ombudsman?:

Yes No

If not, how did you learn about this office?:

Confidentiality / Disclosure
The Small Business Regulatory Enforcement Fairness Act (SBREFA), allows you to keep your identity and other information private, and limit its access only to the Office of the Ombudsman (See 15 U.S.C. 657 (b) (2) (B)). However, by requesting confidentiality the federal agency may not have sufficient information to investigate your specific problem, possibly delaying or preventing any potential resolution of your situation.

I request that my information be kept confidential.

Yes No

(If yes, results may be limited.)

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.

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Last modified: 05/15/2009 12:00:00 AM ... Version: 1.0