SBA Form 480 US Small Business Size Status Declaration

	OMB Approval No. 3245-0009 Expiration Date mm/dd/yyyy
U.S. SMALL BUSINESS ADMINISTRATION SIZE STATUS DECLARATION
This form must be completed by a business concern (“Applicant”) before it can receive financing or consulting and advisory services from a small business investment company licensed by SBA (“Licensee”). The Applicant should complete Part A and Part B (if necessary), sign the Applicant’s certification, and return the form to the Licensee from whom it is seeking assistance. The Licensee should sign the Licensee’s certification and retain the form in its files. Please do not send forms to SBA or to the Office of Management and Budget.
Name and address of Licensee	Name and address of Applicant
Applicant’s Form of Organization: ___Corporation ___Partnership ___Limited Liability Company ___Proprietorship
PART A
Yes No Does the Applicant business have any Affiliates? If yes, attach a list to this form. ___ ___ Affiliation exists when one individual or entity controls or has the power to control another or a third party or parties controls or has the power to control both.  SBA considers factors such as ownership, management, previous relationships with or ties to another entity, and contractual relationships when determining whether affiliation exists.  The complete definition of affiliation is found at 13 CFR 121.103.  (See also, 13 CFR 121.107 and 121.301.) Examples of Affiliates include: (1) a parent company; (2) subsidiaries and other companies that are owned or controlled by the Applicant; (4) companies under common management with the Applicant; and (5) companies that have entered into agreements to merge with the Applicant.   Does Applicant (including affiliates) have tangible net worth in excess of $18,000,000? (Tangible net worth = total net worth minus goodwill) ___ ___ Does Applicant (including affiliates) have average net income after Federal income taxes (excluding any carry-over losses) for the preceding 2 completed fiscal years in excess of $6,000,000? ___ ___
PART B
Applicant must complete this part only if the answer to either question in Part A was “Yes”. Applicant must not exceed the size standard for (1) the industry in which the Applicant combined with its affiliates is primarily engaged, and (2) the industry in which the Applicant alone is primarily engaged. Find the appropriate industry size standard under the NAICS code for your primary industry in 13 CFR 121.201.
Primary industry (include NAICS code): Applicant combined with affiliates__________________ Applicant alone__________________
Total annual receipts of Applicant (excluding affiliates) for each of its 3 most recently completed fiscal years (see 13 CFR 121.104): Year ended ______________ $___________________ Year ended ______________ $___________________ Year ended ______________ $___________________
Applicant’s average number of employees (excluding affiliates) based on the number of persons employed on a full-time, part-time, temporary, or other basis during each of the pay periods of the preceding 12 calendar months (see 13 CFR 121.106): ________________________

Affiliates of Applicant (domestic and foreign)—Names and full addresses		Total annual receipts of affiliates (excluding Applicant) for past 3 completed fiscal years	Average no. of persons employed by affiliates (excluding Applicant) on full-time, part-time, temporary or other basis during each of the pay periods of the preceding 12 calendar months
a.		a. Yr.________ $____________ Yr.________ $____________ Yr.________ $____________ 3-year average $____________	a. ______________________
b.		b. Yr.________ $____________ Yr.________ $____________ Yr.________ $____________ 3-year average $____________	b. ______________________
c.		c. Yr.________ $____________ Yr.________ $____________ Yr.________ $____________ 3-year average $____________	c. ______________________
Applicant’s Certification: Applicant, through its duly authorized officer, hereby certifies that all information herein and in attachments hereto is true and complete to the best of its knowledge and belief. Applicant further certifies that it intends to conduct, for a period of not less than 1 year from the date of the final disbursement of the funds involved in the subject financing and for a period of not less than 1 year from the date of the commencement of the consulting or advisory services, as a regular and continuous business operation, the business operation for which the application for financing or consulting or advisory services is being made. ____________________________________ Name of Applicant 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.
Date:	By: (Signature of Officer)			Title:
Licensee’s Certification: Based upon all the information available to us, including all information and facts obtained through our own investigation, the Licensee has concluded that the Applicant is a small business concern within the requirements of the Small Business Investment Act of 1958, as amended, and the Regulations of SBA thereunder. 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.
Date:	By: (Signature of Authorized Official)			Title:
PLEASE NOTE: The estimated burden for completing this form is 10 minutes 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 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, Washington, D.C. 20416, and/or Office of Management and Budget, Clearance Officer, Paperwork Reduction Project (3245-0009), Washington, D.C. 20503.

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SBA Form 480 (11-10) Previous Editions Obsolete