Form SBA FORM 770 SBA FORM 770 FINANICAL STATEMENT OF DEBTOR

SBA FORM 770 (10-08) SOP 50 51 PREVIOUS EDITION OBSOLETE

Purpose of this Form: To obtain information needed to evaluate your ability to repay your debt. Disclosure is voluntary. However, failure to disclose will
prevent consideration of a debt resolution agreement.

With knowledge of the penalties for false statements provided by 18 United States Code 1001 ($10,000 fine and/or five years imprisonment) and with knowledge that
this financial statement is submitted by me to affect action by the Government. I certify that all the above statements, and all information submitted with this form, are
true and correct and that it is a completed statement of all my income and assets, real and personal, whether held in my name or by another.

Any Person concerned with the collection of this information, its voluntariness, disclosure or routine use under the Privacy Act may contact the Freedom of
Information/Privacy Acts Office, Small Business Administration, 409 3rd St., S.W., Washington, D.C. 20416

SBA FORM 770 (10-08) SOP 50 51 PREVIOUS EDITION OBSOLETE

SBA FORM 770 (10-08) SOP 50 51 PREVIOUS EDITION OBSOLETE