Sba 480 Size Status Declaration

U.S. SMALL BUSINESS ADMINISTRATION
SIZE STATUS DECLARATION

OMB Approval No. 3245-0009
Expiration Date 08/31/2007

This form must be completed by a business concern (“Applicant”) before it can receive financing or
consulting and advisory services from a small business investment company licensed by SBA
(“Licensee”). The Applicant should complete Part A and Part B (if necessary), sign the Applicant’s
certification, and return the form to the Licensee from whom it is seeking assistance. The Licensee
should sign the Licensee’s certification and retain the form in its files. Please do not send forms to
SBA or to the Office of Management and Budget.
Name and address of Licensee

Name and address of Applicant

Applicant’s Form of Organization: ___Corporation ___Partnership ___Limited Liability Company
___Proprietorship
PART A
1. Does Applicant (including affiliates) have tangible net worth in excess of
$18,000,000? (Tangible net worth = total net worth minus goodwill)
2. Does Applicant (including affiliates) have average net income after Federal income
taxes (excluding any carry-over losses) for the preceding 2 completed fiscal years
in excess of $6,000,000?

Yes

No

___

___

___

___

PART B
Applicant must complete this part only if the answer to either question in Part A was “Yes”. Applicant
must not exceed the size standard for (1) the industry in which the Applicant combined with its
affiliates is primarily engaged, and (2) the industry in which the Applicant alone is primarily engaged.
Find the appropriate industry size standard under the NAICS code for your primary industry in 13 CFR
121.201.
1. Primary industry (include NAICS code):
Applicant combined with affiliates__________________ Applicant alone__________________
2. Total annual receipts of Applicant (excluding affiliates) for each of its 3 most recently completed
fiscal years (see 13 CFR 121.104):
Year ended ______________
$___________________
Year ended ______________
$___________________
Year ended ______________
$___________________
3. Applicant’s average number of employees (excluding affiliates) based on the number of persons
employed on a full-time, part-time, temporary, or other basis during each of the pay periods of the
preceding 12 calendar months (see 13 CFR 121.106): ________________________

SBA Form 480 (3-01) Previous Editions Obsolete

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4. Affiliates of Applicant
(domestic and
foreign)—Names and
full addresses

Total annual receipts of affiliates
(excluding Applicant) for past 3
completed fiscal years

a.

a.
Yr.________ $____________
Yr.________ $____________
Yr.________ $____________
3-year average $____________

b.

c.

b.
Yr.________ $____________
Yr.________ $____________
Yr.________ $____________
3-year average $____________
c.
Yr.________ $____________
Yr.________ $____________
Yr.________ $____________
3-year average $____________

Average no. of persons employed by
affiliates (excluding Applicant) on
full-time, part-time, temporary or
other basis during each of the pay
periods of the preceding 12 calendar
months
a. ______________________

b. ______________________

c. ______________________

Applicant’s Certification: Applicant, through its duly authorized officer, hereby certifies that all
information herein and in attachments hereto is true and complete to the best of its knowledge and belief
and that it intends to conduct, for a period of not less than 1 year from the date of the final disbursement
of the funds involved in the subject financing and for a period of not less than 1 year from the date of
the commencement of the consulting or advisory services, as a regular and continuous business
operation, the business operation for which the application for financing or consulting or advisory
services is being made.
____________________________________
Name of Applicant
Date:

By: (Signature of Officer)

Title:

Licensee’s Certification: Based upon all the information available to us, including all information and
facts obtained through our own investigation, the Licensee has concluded that the Applicant is a small
business concern within the requirements of the Small Business Investment Act of 1958, as amended,
and the Regulations of SBA thereunder.
Date:

By: (Signature of Authorized Official)

Title:

PLEASE NOTE: The estimated burden for completing this form is 10 minutes per response. You will not be required to
respond to this information collection if a valid OMB approval number is not displayed. 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, D.C. 20416, and/or Office of Management and
Budget, Clearance Officer, Paperwork Reduction Project (3245-0009), Washington, D.C. 20503.
SBA Form 480 (3-01) Previous Editions Obsolete

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