Form SBA FORM 1031 SBA FORM 1031 PROTFOLIO FINANCING REPORT

SBA Form 1031

OMB No. 3245-0078
Expiration Date mm/dd/y y y y

U.S. Small Business Administration
Portfolio Financing Report

Name of Licensee

License Number

00/00-0000

Part A - Small B usiness Concern Data
2. Employer Identification Number

1. Name of Small Concern
3. Street Address
4. City

5. State

8. Small Business FAX

6. Zip Code

7. County

9. Contact P erson for FAX
11. Form of Business

10. Date Business Established
12. NAICS Code

Industry

13. P ercentage of Small Concern (if any) Owned by:
Black or African American:

%

American Indian or Alaska Native:

Hispanic or Latino:

%

%

Native Hawaiian or Other P acific Islander:
%

14. P ercentage of Small Concern Owned by a) Women (if any)
15a. CEO or P resident:

00-0000000

b) Veterans (if any)

Asian:
% White:

%
%

%

Woman:

15b. CEO or P resident (may select one or more)
Black or African American:

American Indian or Alaska Native:

Hispanic or Latino:

Asian:

Native Hawaiian or Other P acific Islander:

White:

Part B - Pref inancing Inf ormation
17. Stage of Company at Financing:

16. P refinancing Status
18. Small Business Concern's P re-Money Valuation:

19. Fiscal Year End Immediately P rior to Date of Financing (Month/Day/Year)
20. Gross Revenue for P rior Fiscal Year

21. After-Tax P rofit (Loss) for P rior Fiscal Year

22. Income Taxes for P rior Fiscal Year: Federal
23. Net Worth

State

Local

24. Number of Employees

Part C - Financing Inf ormation
25. a. Date of Financing

b. Date of Disbursement

26. Did Licensee lead this investment?

27. P urpose of Financing (P ercentage of financing that will be used to support each category below. P ercentages should total to 100%.)
a. Working Capital or Inventory P urchase
b. P lant Modernization or Leasehold Improvement
c. Acquisition of All or P art of an Existing Business
d. Consolidation of Obligations or Non-SBIC Debt Refunding
e. New Building or P lant Construction

f. Acquisition of Machinery and Equipment
g. Land Acquisition or Construction on Existing Land
h. Marketing Activities
i. Research and Development
j. Other

28 Is this the First Financing of this Small Business by the Licensee?
29. Financing instruments and Applicable Amounts (for participations, include Licensee's portion only):
Instrument
Amount
Initial Interest Rate(s)
% Actual Ownership
Loan Only
Debt with Equity Features
Equity Only
Total Licensee Financing

%
%
%

30. Total Size of Financing Round for Small Business Concern:
31. Comments
Part D - Transmission Verif ication

SBA Form 1031 (06/07) Previous Editions Obsolete

Transmission Date

SBA Form 1031

U.S. Small Business Administration

OMB No. 3245-0078
Expiration Date mm/dd/y y y y

Portfolio Financing Report
If y ou have leverage or a leverage commitment, file Form 1031A (Portfolio Financing Report Certification) semiannually with y our semi-annual valuation
report and y our y ear-end Form 468 (Annual Financial Report). If y ou do not have leverage or a leverage commitment, file Form 1031A annually with y our
Form 468.
PLEASE NOTE: The estimated burden for completing 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 display ed. If y ou 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, Clearance Officer, Paperwork Reduction Project (3245-0078), Washington, DC 20503. PLEASE DO NOT SEND FORMS TO OMB.

SBA Form 1031 (06/07) Previous Editions Obsolete