Form SBA Form 857 SBA Form 857 Request for Information Concerning Portfolio Financing

OMB Approval No. 3245-0109

Expiration Date: xx/xx/xxxx

REQUEST FOR INFORMATION CONCERNING PORTFOLIO FINANCING

Investment Division/Small Business Investment Companies

Name of SBIC___________________________ Name of Small Business__________________________

1. What are the terms and the unpaid balance of your company’s financing from the SBIC?

2. Does the SBIC own an equity interest in your company (shares of stock, partnership interest, etc.)? Yes____ No____ If yes, please indicate the number of shares, the percentage or ownership, and the purchase price paid for such equity interest.

3. Have any warrants, options, or any other forms of equity interest been issued by your company to the SBIC? Yes____ No____ If yes, what are the terms and the conditions of these instruments, including dates, numbers of shares, prices, etc.?

4. How were the proceeds of this financing used by your company?

5. Are any of the officers, directors or owners of your company related to or affiliated in any way with:

(a) The SBIC or its officers, directors or owners? Yes____ No____

2. (b) Any other SBIC or its officers, directors or owners? Yes____ No____

3. If the answer to either of the above is yes, please furnish details.

6. Who were the officers, directors and/or owners of your company at the time of the financing?

7. Any other comments you consider pertinent:

Name_____________________________________________

Title______________________________________________

Signature__________________________________________ Date_________________

Confidential information will be protected from disclosure to the extent permitted by law.

PLEASE NOTE: The estimated burden for completing this form is 1 hour per response. You are not required to respond to any collection of information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to U.S. Small Business Administration, Chief, AIB, 409 3^rd St., S.W., Washington D.C. 20416 and Desk Officer for the Small Business Administration, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503 (OMB Approval 3245-0109). PLEASE DO NOT SEND FORMS TO OMB.

SBA Form 857 (11/09) Previous Editions Obsolete