Form 1081 Statement of Personal History

OMB APPROVAL NO.: 3245-0080
EXPIRATION DATE: 12/31/2006

U.S. Small Business Administration

STATEMENT OF PERSONAL HISTORY
(FOR USE BY NON-BANK LENDERS, CERTIFIED DEVELOPMENT
COMPANIES, AND MICROLENDERS)
Name of Non-Bank Lender, Certified Development Company, or Microlender
Address (Street, City, State and Zip Code) of Non-Bank Lender, Certified Development Co., or Microlender

1.

Applicant's Name in Full:

2.

Date of Birth (month, day & year)

Middle Name (if none, so state)

First

4. U.S. Citizen?

Yes

Last

3. Place of Birth (City and State or Foreign Country)

No

If no, are you a Lawful Permanent resident alien?

Yes

No

5. Social Security Number:

If non -U.S. citizen provide alien registration number:

6. Starting with present address, attach a list of residence addresses for the last ten years using the following format :
T1

From (Date)

To (Date)

Address

7.

Employment and Professional History and Education: Attach a summary of (a) business or professional experience
during the last ten years up to and including the present, stating the periods of each primary activity; the names,
addresses and nature of business of the concerns or entities with which associated; title/and position in such
concerns; and basic functions and responsibilities; (b) summary of your education showing highest level attained
(such as high school graduate, bachelor's degree, master's degree, etc.-- giving, when applicable, name of higher
educational institution, your specialization, and date of degree); and (c) a summary of any special experience or
qualifications pertinent to responsibilities in connection with the operation of the Non-Bank Lender, Certified
Development Company, and Microlenders.

8.

Present Affiliations: Attach a list of all business concerns with which you are presently affiliated as an officer,
director, or in any other official capacity, or by way of direct or indirect ownership or control of 10% or more of any
class of, stock of, or proprietary interest in, such concerns. Show names, addresses, and nature of business of such
concerns, and details of relationships and ownership, including the percentage of any stock or proprietary interest
owned.

Yes

No

9. Have you ever been, directly or indirectly, the subject of an insolvency, bankruptcy, or creditor's rights
proceedings, or has any corporation of which you have been an officer, director, or controlling shareholder
been the subject of such proceedings? (If yes, furnish complete details of such proceedings in a separate
exhibit, including, if pertinent, the court, title of proceedings, date and docket number, as well as the
ultimate disposition.)
10a. Are you presently under indictment, on parole or probation?
(If yes, indicate date parole or probation is to expire.)

10b.

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)

10c. Have you ever been convicted, placed on pretrial diversion, or placed on any form of probation, including
adjudication withheld pending probation, for any criminal offense other than a minor vehicle violation?

SBA Form 1081 (10-03) Previous Edition is Obsolete

Yes

No

11. Have you, or has any corporation, partnership or other business entity with which you are presently or
have heretofore been affiliated (as defined in Item 8, Page 1), ever been charged with or convicted of a
felony or other criminal offense involving dishonesty or breach of trust, or found civilly liable or permanently
or temporarily enjoined by a court by reason of any act or practice involving fraud or breach of trust? (If
yes, furnish relevant details of any such proceedings in a separate exhibit, including the information,
indictment or complaint and the court, title of proceedings, date and docket number.)
12. Have you ever been refused bond? (If yes, explain.)
13. Are you associated with any other Non-Bank Lender, Certified Development Company, or Microlender? (If
yes, explain.)
14. During any part of the past five years has a request for financial assistance been made to any Federal
agency by you or any corporation, partnership or other business entity with which you are presently or
have been heretofore affiliated (as defined in Item 8, Page 1)? (If yes, furnish details in a separate exhibit,
including current status of any assistance received.)
15. To your knowledge, is any SBA employee or any member of an Advisory Council for the Small Business
Administration related to you by blood, marriage, or adoption and/or associated with you through having
any past or present, direct or indirect, financial interest in or affiliation with any concern of which you are a
director, officer or owner of 10% or more of any class of its stock or other proprietary interest? (If yes, list
their names, addresses, and relations.)
16. If you own or will own 10% or more of any class of the stock of the Non-Bank Lender, Certified
Development Company, or Microlender were borrowed funds used in purchasing said stock? (If yes, give
full details including your net worth, amount borrowed or to be borrowed, security and/or guarantors and
terms of repayment.)
17. Has any concern with which you are affiliated directly or indirectly borrowed funds from any Non-Bank
Lender, Certified Development Company, or Microlender? (If yes, give all pertinent details including the
names of all parties to the transaction, the amounts involved, terms, use of proceeds, etc.)

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.

The information on this form will be used in connection with an investigation of your experience and character.
It is against SBA policy to provide assistance not in the best interests of the United States, i.e., if there is reason
to believe that the effect of such assistance will be to encourage or support, directly or indirectly, activities
inimical to the security of the United States.
The nature and scope of the investigation may include contact with banks, other financial institutions,
individuals, business associates, law enforcement offices, and any other areas which will assist SBA in making
an adequate appraisal of your business reputation, character, management experience and financial
soundness. This constitutes the notification required by Section 606 of the Federal Fair Credit Reporting Act.
CAUTION: Knowingly making a false statement on this form is violation of Federal law and could result in criminal prosecution, significant civil
penalties punishable under 18 USC 1001 by imprisonment of not more than five years and/or a fine of not more than $10,000; and under 15 USC 645
by imprisonment of not more than two years and/or a fine of not more than $5,000.

Certificate: I hereby certify that the foregoing is true and complete to the best of my knowledge and belief.

Signature

Title

Date

PLEASE NOTE: The estimated burden for completing this form is 30 minutes 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 (3245-0080). PLEASE DO
NOT SEND FORMS TO OMB.

FOR SBA USE ONLY
SBA Form 1081 (10-03) Previous Edition is Obsolete

No.

Privacy Act (5 V.S.c. 552a)
A 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. Additionally, SBA is
specifically authorized to verify your criminal history, or lack thereof, pursuant to section 7(a)(1)(B), 15
use Section 636(a)(I)(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 use Sections 634(b)(11) and 687(b)(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.
The Privacy Act authorizes SBA to make certain "routine uses" of information protected by that
Act. One such routine use for SBA's investigative files system of records is that when this
information indicates a violation or potential violation oflaw, 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. Another routine use is disclosure
toother Federal agencies conductingbackgroundchecks; only to the extent the
information is relevant to the requesting agencies' function. See. 69 F.R. 58598,
5861 27 (and as amended from time to time) for additional background and other routine uses.

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This law permits a Federal agency to require each person doing businesswith that agency to furnish to
that agency that person's taxpayer identification number.

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Freedom of Information Act (5 V.S.C. 552)
This law provides, with some exceptions, that SBA must supply information reflected in agency files and
records to a person requesting it. Information about approved loans that will be automatically released
includes, among other things, statistics on our loan programs (individual borrowers are not identified in
the statistics) and other information such as the names of the borrowers (and their officers, directors,
stockholders or partners), the collateral pledged to secure the loan, the amount of the loan, its purpose in
general terms and the maturity. Proprietary data on a borrower would not routinely be made available to
third parties. All requests under this Act are to be addressed to the nearest SBA office and be identified as
a Freedom of Information request.

SBA Form 1081 (10-03) Previous Edition is Obsolete

Paperwork

Reduction Act (44 V.S.C. Chapter 35)

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