SBA FORM 4SCHA Schedule of Collateral

OMB Approval No.: 3245-0016

Expiration Date

U.S. SMALL BUSINESS ADMINISTRATION

SCHEDULE OF COLLATERAL

Exhibit A

Applicant

Street Address

City State Zip Code

LIST ALL COLLATERAL TO BE USED AS SECURITY FOR THIS LOAN

Section I – REAL ESTATE

Attach a copy of the deed(s) containing a full legal description of the land and show the location (street address) and city where the deed(s) is recorded. Following the address below, give a brief description of the improvements, such as size, type of construction, use, number of stories, and present condition (use additional sheet if more space is required).

LIST OF PARCELS OF REAL ESTATE
Address	Year Acquired	Original Cost	Market Value	Amount of Lien	Name of Lienholder
Description(s)

SBA Form 4, Schedule A (4-08) Previous Editions Obsolete

SUBMIT COMPLETED APPLICATION TO LENDER OF CHOICE

Section II- PERSONAL PROPERTY

All items with an original value greater than $5,000 listed herein must show manufacturer or make, model, year, and serial number. Items with no serial number must be clearly identified (use additional sheet if more space is required).

Description-Show Manufacturer, Model, Serial No.	Year acquired	Original Cost	Market Value	Current Lien Balance	Name of Lienholder

All information contained herein is TRUE and CORRECT to the best of knowledge. If you knowingly make a false statement or overvalue a security to obtain a guaranteed loan from SBA, you can be fined up to $250,000 and/or imprisoned for not more than five years under 18 USC 1001; if submitted to a Federally insured institution, under 18 USC 1014 by Imprisonment of not more than twenty years and/or a fine of not more than $1,000,000. I authorize the SBA’s Office of Inspector General to request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for programs authorized by the Small Business Act, as amended.

Name Date

Name Date

NOTE: The estimated burden for completing this form is 0.5 hours per response. You will not be required to respond to collection of information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to the U.S. Small Business Administration, Chief, AIB, 409 3^rd. St., S.W. Washington, D.C., 20416 and Desk Office for Small Business Administration, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503.

OMB Approval (3245-0016).

SBA Form 4, Schedule A (4-08) Previous Editions Obsolete