Form SBA 1941A SBA 1941A Financing Eligbility Statement Social Disadvantage

OMB Control No. 3245-0301 Expiration Date 11/30/2010

FINANCING ELIGIBILITY STATEMENT - "SOCIAL DISADVANTAGE"

(FOR INDIVIDUALS WHO ARE MEMBERS OF A DESIGNATED GROUP)

Individual's Name__________________________________________________

Applicant Business Name____________________________________________

INSTRUCTIONS:

Answers to the following questions will be used to determine your personal eligibility for your business to receive financing under Section 301(d) of the Small Business Investment Act. Under this provision, to be eligible to receive financing, you must meet the criteria stipulated in Appendix 1 of this form. Please provide complete responses to each question. When your answers require additional space, use plain white paper properly identifying the item number to which you are responding. Omission of any information requested will result in a delay in the review and consideration of your application.

I. SOCIAL DISADVANTAGE

A. I am claiming social disadvantage because of my identification as a:

____ Black American

____ Hispanic American

____ Native American (American Indian, Eskimo, Aleut or Native Hawaiian)

____ Asian Pacific American [An individual with origins from Burma, Thailand, Malaysia, Indonesia, Singapore, Brunei, Japan, China, Taiwan, Laos, Cambodia (Kampuchea), Vietnam, Korea, The Philippines, U. S. Trust Territory of the Pacific Islands (Republic of Palau), Republic of the Marshall Islands, Federated States of Micronesia, The Commonwealth of the Northern Mariana Islands, Guam, Samoa, Macao, Hong Kong, Fiji, Tonga, Kiribati, Tuvalu, or Nauru]

____ Subcontinent Asian American (An Individual with origins from India, Pakistan, Bangladesh, Sri Lanka, Bhutan, the Maldives Islands or Nepal)

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II. Ownership and Control

A. Describe how socially or economically disadvantaged persons have a majority voting interest on the board of directors or any other governing body of the concern being financed (provide supporting documentation).

B. If your business is a corporation or a general partnership, explain how the eligible disadvantaged person(s) will own more than 50% of the voting interest of the business after receiving financing from the Small Business Investment Company (provide supporting documentation).

C. Is the business concern a limited partnership? ____ Yes ____ No

If Yes, explain (and provide documentation) to show whether the eligible disadvantaged person(s) are either the general partners, or that they control any corporate general partners

D. Indicate the percentage of the economic interest that eligible disadvantaged person(s) hold in the business (provide supporting documentation). (Economic interest is the right to proportionate distributions after all secured and unsecured debts have been satisfied.)

E. Do the eligible disadvantaged person(s) hold less than 50% of the economic interest in the company? If so, fully describe all other investors holding an economic interest in the company.

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III. CERTIFICATION OF ELIGIBILITY

I hereby certify that all information in this Statement, including exhibits and supporting documentation, is true and complete to the best of my knowledge and is submitted for consideration of financing from an entity licensed by the U.S. Small Business Administration.

I acknowledge that any statement made in this Financing Eligibility Statement, including exhibits and supporting documentation, which I know to be false, may, under provisions of the Small Business Act and/or the Small Business Investment Act, and 18 U.S.C. 1001, subject me to a fine, imprisonment, or both.

_________________________________________

Name of Business

_________________________________________

Typed Name and Title of Qualifying Person

_________________________________________

Signature of Qualifying Person

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IV. LICENSEE CERTIFICATION

I hereby certify that the licensee has reviewed all information provided by the small business concern in support of its application for financing, and determined that all documentation and other information supports the eligibility of the applicant and establishes that the concern is owned and managed by an eligible socially or economically disadvantaged person(s), as defined in the Small Business Investment Act and SBA Policy and Procedural Release # 2017, dated June 22, 1994.

I acknowledge that any statement made in this Financing Eligibility Statement, including exhibits and supporting documentation, which I know to be false, may, under provisions of the Small Business Act and/or the Small Business Investment Act, and 18 U.S.C. 1001, subject me to a fine, imprisonment, or both.

_________________________________________

Name of SBIC/SSBIC

_________________________________________

Typed Name of President or General Partner

_________________________________________

Signature of President or General Partner

Please Note: The estimated burden for completing this form is 2 hours 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, DC 20416, and/or Office of Management and Budget, Clearance Officer, Paperwork Reduction Project (3245-0301), Washington, DC 20503. PLEASE DO NOT SEND FORMS TO OMB.

SBA Form 1941A (4-95)