Form `SBA FORM 856 `SBA FORM 856 DISCLOSURE STATEMENT LEVERAGED LICENSEES

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OMB CONTROL NO. 3245-0118

EXPIRATION DATE 02/28/09

U.S. SMALL BUSINESS ADMINISTRATION

DISCLOSURE STATEMENT

LEVERAGED LICENSEES

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TO: SBA EXAMINER

In connection with your examination of _______________________________________, as of _______________________, I represent that to the best of my knowledge and belief: (Write “None” where applicable.)

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1. All known liabilities of this licensee were recorded on the books of account except for the following:

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2. No litigation was in progress or pending, or is now in progress or pending, except for the following:

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3. The licensee has not provided financings to any concerns which have also received financing from Associates (as defined in 13 CFR Section 107.50) except for the following:

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4. No assets of the licensee were pledged or otherwise hypothecated as security for any liability except:

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5. No licensee capital stock (or licensee partnership interest) was pledged or encumbered except:

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6. The licensee is guaranteeing the following portfolio company loans: (List name of company, amounts guaranteed, payments made.)

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7. Outstanding financing commitments are:

8. The information contained on Schedule 8, Annual Report, SBA Form 468, as of ______________ regarding principals of this licensee is the same, except for the following:

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9. The licensee or its Associates provided management consultant services or technical services to the following portfolio companies:

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10. The licensee or its Associates assumed control over the following portfolio companies:

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SBA FORM 856 (9/01) REF SOP 90 35 PREVIOUS EDITIONS ARE OBSOLETE

11. As of ________________________, there are no investors identified as institutional investors in the Capital Certificate who have subsequently reported a net worth below the minimum requirement, except for the following: _____________________________________________.

11. The licensee’s Associates are also officers, directors, or employees (or partners) of portfolio companies as follows:

NAME OF PORTFOLIO COMPANY	NAME OF ASSOCIATE	POSITION IN PORTFOLIO COMPANY	DATE POSITION TAKEN

11. The licensee’s Associates have direct or indirect financial interest in portfolio companies as follows:

NAME OF PORTFOLIO COMPANY AND DISCRIPTION OF FINANCIAL INTEREST, STOCK OWNERSHIP, WARRANTS, PARTNERSHIP INTEREST, LOAN, ETC.	DATE FINANCIAL INTEREST ACQUIRED	COST BASIS	NAME OF ASSOCIATE

11. The licensee’s Associates received title to or use of (with or without financial consideration) assets from portfolio companies or from the licensee as follows:

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SIGNATURE AND TITLE DATE

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