Sba 468 Financial Report

R

OMB No: ###-###

Exp. Date:

URAL BUSINESS INVESTMENT PROGRAM
U. S. SMALL BUSINESS ADMINISTRATION, INVESTMENT DIVISION
409 Third Street, S.W. Washington, DC 20416 Tel: (202) 205-6510; Fax: (202) 205-6959

RURAL BUSINESS INVESTMENT COMPANY

SBA Form 468

Schedule 9

Economic Development Impact Assessment

Instructions: Rural Business Investment Companies (RBICs) must file this Schedule 9 of SBA Form 468 for each Financing the RBIC makes. (See 7 CFR 4290.630(e).) File this Schedule 9 with SBA annually, together with the remainder of SBA Form 468, as required in 7 CFR 4290.630.

RBIC

RBIC Name

RBIC #

Portfolio Concern

Enterprise name									EIN #
Street Address
City			State			Zip			County
Contact Person									Phone
Is the Portfolio concern a Rural Business Concern?								Yes			No

Rural Area in which Rural Business Concern’s Principal Office is located (i.e., census tract number or specific qualifying criteria; or attach a print-out of search result from SBA’s web site at http://www.sba.gov/INV/RBIC/):

THE INFORMATION COLLECTED ON THIS FORM WILL BE KEPT CONFIDENTIAL

TO THE EXTENT PERMITTED BY APPLICABLE LAW.

Please indicate the start and end dates of the Portfolio Concern’s most recent fiscal year, using the following format (MM/DD/YY):

Fiscal year start date:	Fiscal year end date:

I. EMPLOYMENT INFORMATION

1. a. How many employees reside in a Rural Area? (An employee resides in a Rural Area if the zip code of the employee’s residence as reported on the IRS Form W-2 at the end of the tax year, falls within such an area. Use geographic mapping/searching page on SBA’s web site at http://www.sba.gov/INV/RBIC/ to look up whether a zip code falls within such an area.)

Enter amount:

2. What percentage of employees reside in a Rural Area?

Enter Percentage:

c. List the number of full-time employees by wage category:

Annual Income from Wage/Salary	Number of Employees	Total Amount of Wage/Salary
$25,000 and below
$25,000 to $50,000
over $50,000
Totals:

2. Did the Portfolio Concern offer medical coverage of any kind or payment in lieu of medical coverage at the end of the most recent fiscal year?

Yes _____ No _____

Percentage of portfolio concern’s workforce:

3. At the end of the most recent fiscal year, did the Portfolio Concern offer pension plan (other than Social Security), savings plan, or 401K plan or the equivalent to full-time employees?

Yes _____ No _____

Percentage of portfolio concern’s workforce:

II. FINANCIAL INFORMATION

4. Ownership of the Portfolio Concern:

a. How much of the Portfolio Concern’s equity is owned by residents of Rural Areas? _________%

b. What is the book value of that ownership at the end of the most recent fiscal year? $_____________

NOTE: FOR QUESTION 5, PLEASE USE “N/A” WHEN NOT APPLICABLE OR “0” WHEN THE AMOUNT IS ZERO

5. What were the total amounts of the following taxes the Portfolio Concern paid during the most recent fiscal year?

a. What was the real estate tax paid on business-related property during the most recent fiscal year? $________________

b. What was the property tax (on business equipment, inventory, etc.) paid during the most recent fiscal year? $________________

6. How much financing did the Portfolio Concern receive from all sources during the most recent fiscal year?

1. Equity capital from RBIC Companies $________________

2. Other equity $________________

3. Bank loans $________________

4. Other loans $________________

5. Line of credit $________________

6. Total financing $________________

SBA is collecting the information on this Schedule 9 of SBA Form 468 in accordance with section 384K(a)(2) of the Consolidated Farm and Rural Development Act (7 USC 2009cc-10(a)(2)) for the purpose of determining the extent of the economic development impact of the financing. The information collected on this form is required in order for the RBIC to continue to receive SBA assistance. SBA is collecting this information on behalf of the U.S. Department of Agriculture (USDA) pursuant to a delegation of authority by USDA to SBA (7 CFR 4290.45.)

Please note: The estimated burden for completing this form is 4 hours. You are not required to respond to this form unless it displays a current Office of Management and Budget (OMB) approval number. The information collected on this form will be kept confidential to the extent permitted by law. If you have questions or comments concerning this estimate or other aspects of this information collection, please contact the U.S. Small Business Administration, Chief, Administrative Information Branch, Washington, DC 20416 and/or Office of Management and Budget, SBA Desk Officer, Washington, D.C. 20503. OMB Approval Number ####-####. Please do not send forms to OMB.

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SBA Form 468, Schedule 9 (5/04)