Form SBA Form 1405A SBA Form 1405A Ownership Confirmation for Partnership SBIC's

OMB Control No. 3245-0172

Expiration Date mm/dd/yyyy

U.S. SMALL BUSINESS ADMINISTRATION

OWNERSHIP CONFIRMATION

FOR PARTNERSHIP SBICs

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

1. The records of ______________________ (SBIC) show that as of __________________, you provided a capital commitment totaling $_____________. The SBIC records show that $____________ has been funded and $____________ remains to be paid.

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

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

3. Have any restrictions been imposed on you by the SBIC in addition to those in the partnership agreement?

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

3. Were the funds used to purchase the partnership interest 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 1405A (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.