Form 860 Financial Institution Confirmation Form

OMB Approval No. 3245-0116
Expiration Date:

U.S. Small Business Administration
___________________, 20____
Dear Sir/Madam:
Your completion of the following report will be sincerely appreciated and response is strictly voluntary. If the answer to any item is
"None," please so state. Please reply within ten (10) days. A self-addressed envelope is enclosed for your convenience.

Name of Bank

Account Name per Bank Statement

Street Address

Authorized Signature

City, State, Zip Code
Note: If space provided is inadequate, please enter totals
hereon and attach statement giving full details as called for
by the column headings below.

Examination Manager
Office of SBIC Examinations

1. At the close of business on _______________________, our records showed the following balance(s) to the credit of the above
named customer. In the event that we could ascertain whether there were any balances to the credit of the customer not designated in
this request, the appropriate information is given below.
Amount

Account Name

Account Number

Subject to withdrawal
By check?

Interest bearing?
Give Rate.

$

2. The customer was directly liable to us in respect of loans, acceptance, etc., at the close of business on that date in the total amount
of $__________________, as follows:
Amount

Date of Loan or
Discount

Due Date

Interest
Rate

Paid to

Description of Liability, Collateral, Security Interests,
Liens, Endorsers, etc.

$

3. The customer was contingently liable as endorser of notes discounted and/or as guarantor at the close of business on that date in the
total amount of $______________________, as follows:
Amount

Name of Maker

Date of Note

Due Date

Remarks

$

4. Other direct or contingent liabilities, open letters of credit, and relative collateral, were:

5. Security agreements under the Uniform Commercial Code or any other agreements providing for restrictions, not noted above, were
as follows (if officially recorded, indicate date and office in which filed):

Name

Title

Authorized Signature

___________________, 20____

PLEASE NOTE: The estimated burden for completing this form is 1/2 hour per response. You are not required to respond to any collection of information unless it displays a
currently valid OMB approval number. Comments on the burden should be sent to U.S. Small Business Administration, Chief, AIB, 409 3rd St., S.W., Washington D.C. 20416
and Desk Officer for the Small Business Administration, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503 (OMB
Approval 3245-0116). PLEASE DO NOT SEND FORMS TO OMB.

SBA Form 860 (11/96) Previous Editions Obsolete

OMB Approval No. 3245-0116
Expiration Date:

Confidential information will be protected to the extent permitted by law.

PLEASE NOTE: The estimated burden for completing this form is 1/2 hour per response. You are not required to respond to any collection of information unless it displays a
currently valid OMB approval number. Comments on the burden should be sent to U.S. Small Business Administration, Chief, AIB, 409 3rd St., S.W., Washington D.C. 20416
and Desk Officer for the Small Business Administration, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503 (OMB
Approval 3245-0116). PLEASE DO NOT SEND FORMS TO OMB.

SBA Form 860 (11/96) Previous Editions Obsolete