Sba 1031 Portfolio Financing Report

U.S. Small Business Administration

OMB No. 3245--0078

Portfolio Financing Report

Expiration Date:07/31/2007

Name of Licensee

License Number

Part A - Small Business Concern Data
1. Name of Small Business

2. Employer Identification Number

3. Street Address

4. City

6. ZIP Code

7. County

5. State

8. Small Business FAX

9. Contact Person for FAX

10. Date Business Established

/

1) Corporation 2) Partnership 3) Proprietor 4) Limited Liability Company

11. Form of Business (select one)
12. SIC Code

/

or Industry (if SIC Code is not known)

13. Percentage of Small Concern (if any) Owned by: Blacks

% Hispanics

% Native Americans

Asian Pacific Americans

%

% Subcontinent Asian Americans

%

%

14. Percentage of Small Concern Owned by Women (if any)

Part B - Prefinancing Information
Prefinancing Info Status (select one)

1) New Information 2) Previously Submitted 3) Acquired Business 4) New Business

15. Fiscal Year End Immediately Prior to Date of Financing (Month/Day/Year)
16. Gross Revenue for Prior Fiscal Year $

/

/

17. After-Tax Profit or (Loss) for Prior Fiscal Year $

18. Income Taxes for Prior Fiscal Year: Federal $

State $

Local $

19. Employee Payroll Tax Withholdings for Prior Fiscal Year: Federal $
20. Total Assets $

State and Local $

21. Net Worth (Deficit) $

22. Retained Earnings (Deficit) $

23. Number of Employees

Part C - Financing Information
/

24. Date of Financing

/

/

25. Date of Disbursement

/

26. Purpose of Financing (enter appropriate number(s); 1-10)
1)
2)
3)
4)
5)

6)
Working Capital or Inventory Purchase
7)
Plant Modernization or Leasehold Improvement
8)
Acquisition of All or Part of an Existing Business
9)
Consolidation of Obligations or Non-SBIC Debt Refunding
10)
New Building or Plant Construction

Acquisition of Machinery and Equipment
Land Acquisition or Dwelling Construction
Marketing Activities
Research and Development
Other (specify)

27. Is this the First Financing of this Small Business by the Licensee? ✔ Yes

✔

No

28. Financing Instruments and Applicable Amounts (for participations, include Licensee's portion only):
Instrument

Amount

Loan Only

Initial Interest Rate(s)

$

%

Debt with Equity Features $

%

Equity Only

$

Total Financing

$

% Ownership

%

29. Comments

Part D - Licensee Verification
Transmission Date

/

/

PLEASE NOTE: The estimated burden for the completion of this form is 12 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 (3245-0078),
Washington, D.C. 20503. PLEASE DO NOT SEND FORMS TO OMB.
SBA Form 1031 (07-04) Previous Editions Obsolete
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