Sba Form 2217 Request For Sba Approval Of Management Services Fees And

NEW MARKETS VENTURE CAPITAL PROGRAM

INVESTMENT DIVISION
U. S. SMALL BUSINESS ADMINISTRATION

409 Third Street, S.W. Washington, DC 20416 Tel: (202) 205-6510; Fax: (202) 205-6959

Request for SBA Approval of Management Services Fees and Other Fees

13 CFR 108.900

Instructions: Use this form to request prior approval from SBA for a New Markets Venture Capital Company (NMVCC) (“you”) or its Associate to charge management services fees or other fees to a Small Business before or during the term of a Financing, pursuant to 13 CFR 108.900. Submit this form to SBA at the address shown above.

NMVCC Name:
NMVCC Number:

MANAGEMENT SERVICES FEES:

Name of Small Business to be charged management services fees, upon SBA approval of this request:
Describe the management services you or your Associate will provide to the Small Business.
Who will provide these services to the Small Business, you, or your Associate?
If by an Associate, identify the Associate:
Have you or your Associate entered into, or will you or your Associate enter into, a written contract with the Small Business concerning these services? (attach a copy of the executed or proposed contract)
Will the fees charged be only for management services you or your Associate actually perform for the benefit of the Small Business?
On what basis will you or your Associate provide these services? (e.g., hourly fee, project fee, etc.)
Does the rate you or your Associate will charge exceed the prevailing charge for comparable services by other organizations in the geographic area of the Small Business? (be prepared to demonstrate the basis for your answer, upon SBA’s request)
For management services provided by your Associate only, what is the percentage of fees for these services paid by the Small Business to your Associate, that will be allocated back to you for your benefit? (see 13 CFR 108.900(c)(5))

FEES FOR SERVICE AS A BOARD MEMBER:

Name of Small Business to be charged fees for service as a board member, upon SBA approval of this request:
Describe the services you or your Associate will provide as members of the Small Business’s board of directors.
Who will provide these services to the Small Business, you, or your Associate?
If by an Associate, identify the Associate:
Will these fees exceed fees paid to other outside board members?
If there will be no other outside board members besides you or your Associate, will these fees be reasonable when compared with amounts paid to outside directors of similar companies? (be prepared to demonstrate the basis for your answer, upon SBA’s request)
In what form will the Small Business’s payment of these fees to you or your Associate take? (e.g., cash, warrants, etc.)
For fees for services as a board member by your Associate only, what is the percentage of fees paid by the Small Business to your Associate that will be allocated back to you for your benefit? (see 13 CFR 108.900(d))

TRANSACTION FEES:

Name of Small Business to be charged transaction fees, upon SBA approval of this request:
Describe the transaction fees you or your Associate will charge to the Small Business.
Who will charge these fees to the Small Business, you, or your Associate?
If by an Associate, identify the Associate:
In what form will the Small Business’s payment of these fees to you or your Associate take? (cash, notes, stocks, and/or options.)
For transaction fees paid to your Associate only, what is the percentage of fees paid by the Small Business to your Associate that will be allocated back to you for your benefit? (see 13 CFR 108.900(e)(1))

The NMVCC asks that SBA approve the NMVCC or Associate charging the named Small Business(es) the described fees for management services, services as a member of the board, and/or services relating to transactions.

NMVCC Name (typed)
Signature of Authorized Representative		Date

SBA approves the NMVCC’s request, subject to the following conditions (if any):

Name of SBA Representative
Signature		Date

SBA is collecting the information on this form in accordance with 13 CFR 108.900, for the purpose evaluating a request by a NMVCC for SBA’s prior approval for the NMVCC or its Associate to charge certain fees to Small Businesses. The information collected on this form is required in order for SBA to adequately evaluate the NMVCC’s request.

Please note: The estimated burden for completing this form is 4 hours. You are not required to respond to this form unless it displays a current Office of Management and Budget (OMB) approval number. The information collected on this form will be kept confidential to the extent permitted by law. 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, SBA Desk Officer, Washington, D.C. 20503. OMB Approval 3245-0338. Please do not send forms to OMB.

SBA Form 2217 (5/02) 3