SBA FORM 1405 Stockholders Confirmation for Corporate SBIC

OMB Control No. 3245-0172

Expiration Date mm/dd/yyyy

U.S. SMALL BUSINESS ADMINISTRATION

STOCKHOLDER’S CONFIRMATION

FOR CORPORATE SBICs

Please send the completed form to SBA in the return envelope provided.

1. The records of ______________________ (SBIC) show that as of __________________, the SBIC issued ______ shares of common stock to ______________________ as holder of record for total consideration of $____________.

_____ Correct _____Incorrect (If incorrect, please explain.)

2a. Your unpaid capital commitment of $__________ is due the SBIC and remains outstanding.

_____ Correct _____Incorrect (If incorrect, please explain.)

2b. Is your capital commitment backed by an outstanding letter of credit from a qualified institutional investor?

_____ Yes _____ No (If yes, please explain.)

3. Is the SBIC’s capital stock held by you pledged as collateral or encumbered in any other manner?

_____ Yes _____ No (If yes, please explain.)

3. Have you or do you anticipate receiving directly or indirectly any financing from the SBIC?

_____ Yes _____ No (If yes, please explain.)

3. Are there any “puts”, “calls”, purchase agreements, assignments of voting rights, or other contracts attached to the stock you hold in the SBIC?

_____ Yes _____ No (If yes, please explain.)

3. Were the funds used to purchase the SBIC’s capital stock borrowed? If so, please state the source of borrowed funds and if your net worth is equal to at least twice the amount of the funds borrowed.

I hereby certify that all information herein and in all attachments hereto is true and complete to the best of my knowledge

and belief.

CAUTION: Knowingly making a false statement on this form is a violation of federal criminal statutes, including

18 U.S.C. § 1001, and can be punishable by imprisonment of up to five years and/or a fine of up to $250,000.

_________________________________________ _____________________

Signature and Title Date

SBA Form 1405 (11/10) Previous editions are obsolete

PLEASE NOTE: This information collection is voluntary. The estimated burden for completion of this form is 1 hour per response. You will not be required to respond to this information collection if a valid OMB approval number is not displayed. If you have any 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, 409 3^rd Street, S.W., Washington, DC 20416, or Office of Management and Budget, Clearance Officer, Paperwork Reduction Project (3245-0172), Washington, DC 20503. PLEASE DO NOT SEND FORMS TO OMB.