Form 912 Statement of Personal History

OMB APPROVAL NO.3245-0178
Expiration Date:9/30/2006

Return Executed Copies 1, 2, and 3 to SBA

Please Read Carefully - Print or Type

United States of America
SMALL BUSINESS ADMINISTRATION
STATEMENT OF PERSONAL HISTORY
Name and Address of Applicant (Firm Name)(Street, City, State, and ZIP Code)

Each member of the small business or the development company requesting assistance
must submit this form in TRIPLICATE for filing with the SBA application. This form must
be filled out and submitted by:
1. By the proprietor, if a sole proprietorship.
2. By each partner, if a partnership.
3. By each officer, director, and additionally by each holder of 20% or more of the
ownership stock, if a corporation, limited liability company, or a development company.
SBA District/Disaster Area Office
Amount Applied for (when applicable)

1.

File No. (if known)

Personal Statement of: (State name in full, if no middle name, state (NMN), or if initial
only, indicate initial.) List all former names used, and dates each name was used.
Use separate sheet if necessary.

2. Give the percentage of ownership or stocked owned Social Security No.
or to be owned in the small business or the
development company

First

3. Date of Birth (Month, day, and year)

Middle

Last

4. Place of Birth: (City & State or Foreign Country)

Name and Address of participating lender or surety co. (when applicable and kno wn)

5. U.S. Citizen?
YES
NO
If No, are you a Lawful
NO
YES
Permanent resident alien:
If non- U.S. citizen provide alien registration number:

6. Present residence address:

Most recent prior address (omit if over 10 years ago):

From:

From:

To:
Address:

To:
Address:

Home Telephone No. (Include A/C):
Business Telephone No. (Include A/C):

PLEASE SEE REVERSE SIDE FOR EXPLANATION REGARDING DISCLOSURE OF INFORMATION AND THE USES OF SUCH INFORMATION.
IT IS IMPORTANT THAT THE NEXT THREE QUESTIONS BE ANSWERED COMPLETELY. AN ARREST OR CONVICTION RECORD WILL NOT
NECESSARILY DISQUALIFY YOU; HOWEVER, AN UNTRUTHFUL ANSWER WILL CAUSE YOUR APPLICATION TO BE DENIED.
IF YOU ANSWER "YES" TO 7, 8, OR 9, FURNISH DETAILS ON A SEPARATE SHEET. INCLUDE DATES, LOCATION, FINES, SENTENCES, WHETHER
MISDEMEANOR OR FELONY, DATES OF PAROLE/PROBATION, UNPAID FINES OR PENALTIES, NAME(S) UNDER WHICH CHARGED, AND ANY
OTHER PERTINENT INFORMATION.
7. Are you presently under indictment, on parole or probation?
Yes

No

(If yes, indicate date parole or probation is to expire.)

8. Have you ever been charged with and or arrested for any criminal offense other than a minor motor vehicle violation? Include offenses which have been dismissed, discharged, or
not prosecuted (All arrests and charges must be disclosed and explained on an attached sheet.)
Yes

No

9. Have you ever been convicted, placed on pretrial diversion, or placed on any form of probati on, including adjudication withheld pending probation, for any criminal offense other
than a minor vehicle violation?
Yes

No

10. I authorize the Small Business Administration Office of Inspector General to request criminal record information about me from criminal justice agencies for the purpose of
determining my eligibility for programs authorized by the Small Business Act, and the Small Business Investment Act.
CAUTION: Knowingly making a false statement on this form is a violation of Federal law and could result in criminal prosecution, significant civil penalties, and a denial of your loan,
surety bond, or other program participation. A false statement is punishable under 18 USC 1001 by imprisonment of not more than five years and/or a fine of not more than $10,000;
under 15 USC 645 by imprisonment of not more than two years and/or a fine of not more than $5,000; and, if submitted to a Federally insured institution, under 18 USC 1014 by
imprisonment of not more than thirty years and/or a fine of not more than $1,000,000.
Signature

Title

Date

Agency Use Only
11.

Fingerprints Waived
Fingerprints Required

Date

Approving Authority

Date

Approving Authority

Date Sent to OIG

12.

Cleared for Processing

13.

Request a Character Evaluation

Date

Approving Authority

Date

Approving Authority

(Required whenever 7, 8 or 9 are answered "yes" even if cleared for processing.)

PLEASE NOTE: The estimated burden for completing this form is 15 minutes per re sponse. You are not required to respond to any collection of information un less 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 3245-0178. PLEASE DO NOT SEND FORMS TO OMB.

SBA 912 (10-03) SOP 5010.4 Previous Edition Obsolete

This form was electronically produced by Elite Federal Forms, Inc.

NOTICES REQUIRED BY LAW
The following is a brief summary of the laws applicable to this solicitation of information.
Paperwork Reduction Act (44 U.S.C. Chapter 35)
SBA is collecting the information on this form to make a character and credit eligibility decision to fund or deny you
a loan or other form of assistance. The information is required in order for SBA to have sufficient information to
determine whether to provide you with the requested assistance. The information collected may be checked
against criminal history indices of the Federal Bureau of Investigation.
Privacy Act (5 U.S.C. § 552a)
Any person can request to see or get copies of any personal information that SBA has in his or her file, when that
file is retrievable by individual identifiers, such as name or social security numbers. Requests for information about
another party may be denied unless SBA has the written permission of the individual to release the information to
the requestor or unless the information is subject to disclosure under the Freedom of Information Act.
Under the provisions of the Privacy Act, you are not required to provide your social security number. Failure to
provide your social security number may not affect any right, benefit or privilege to which you are entitled.
Disclosures of name and other personal identifiers are, however, required for a benefit, as SBA requires an
individual seeking assistance from SBA to provide it with sufficient information for it to make a character
determination. In determining whether an individual is of good character, SBA considers the person's integrity,
candor, and disposition toward criminal actions. In making loans pursuant to section 7(a)(6) the Small Business
Act (the Act), 15 USC § 636 (a)(6), SBA is required to have reasonable assurance that the loan is of sound value
and will be repaid or that it is in the best interest of the Government to grant the assistance requested.
Additionally, SBA is specifically authorized to verify your criminal history, or lack thereof, pursuant to section
7(a)(1)(B), 15 USC § 636(a)(1)(B). Further, for all forms of assistance, SBA is authorized to make all
investigations necessary to ensure that a person has not engaged in acts that violate or will violate the Act or the
Small Business Investment Act,15 USC §§ 634(b)(11) and 687b(a). For these purposes, you are asked to
voluntarily provide your social security number to assist SBA in making a character determination and to
distinguish you from other individuals with the same or similar name or other personal identifier.
When this information indicates a violation or potential violation of law, whether civil, criminal, or administrative in
nature, SBA may refer it to the appropriate agency, whether Federal, State, local, or foreign, charged with
responsibility for or otherwise involved in investigation, prosecution, enforcement or prevention of such violations.
See 69 FR. 58598 (2004) for other published routine uses.