Sba Form 2219 Operational Assistance Grant Performance Report

[NMVCC Name]	[OA Recipient Business Name]
OA Award: [Number]	EIN [number]
	Reporting Period [MM/DD/YY-- MM/DD/YY]

N

OMB No: 3245-0332

Exp. Date: 12/31/2011

EW MARKETS VENTURE CAPITAL PROGRAM
OFFICE OF INVESTMENT
U. S. SMALL BUSINESS ADMINISTRATION
409 Third Street, S.W. Washington, DC 20416 Tel: (202) 205-6510; Fax: (202) 205-6959

Operational Assistance (OA) Grant Performance Report

INSTRUCTIONS

• Be sure to fill in the header for this Report.

• Remove all information contained within brackets, including the brackets, and replace with requested data.

• Recipient (“you”) must complete Parts A and B for each Smaller Enterprise receiving Operational Assistance (“OA”) during the reporting period.

• You must complete Part C and the accompanying certification for each reporting period.

Part A - Smaller Enterprise Data

Business name

Street Address

City

State

Zip

County

Phone

Fax

Formation Date

[MM/YY]

NAICS Code or Industry if Code is not known

Is the Smaller Enterprise within your targeted Low Income Geographic Area (LI Area)? [Yes/No]

Part B - Description of Operational Assistance Provided
Did this Smaller Enterprise receive OA in prior reporting periods? [Yes/No]
What was the status of the Smaller Enterprise when it received OA? [check only one]
Portfolio Concern		Prospective Portfolio Concern

1. If the Smaller Enterprise was a prospective Portfolio Concern when it received OA at your direction, how many and what percentage of the Smaller Enterprise’s employees reside in a LI Area? (An employee resides in a LI Area if the zip code of the employee’s residence as reported on the IRS Form W-2 at the end of the most recent tax year, falls within such an area. Use the geographic mapping/searching page of SBA’s web site at http://www.sba.gov/INV/NMVC to look up whether a zip code falls within such an area.)

Number

Percentage of total work force

%

2. Describe the OA provided and how such OA specifically helped in the business development of the Smaller Enterprise.

3. How did you identify and assess the Smaller Enterprise’s need for OA?

4. How did you design the OA to meet the specific needs of this particular Smaller Enterprise?

5. Identify the person(s) who provided the OA to the Smaller Enterprise, and state whether the person(s) are your employees or are a third party.

6. State whether the person(s) who provided the OA were licensed professionals. If no licensed professional was involved, why did you believe that the services of such a professional was not necessary?

Part C - Summary of Operational Assistance Activities

1. Summarize your activities under your OA grant award during the reporting period including a comparison to your project and budget plan.

2. Discuss your actual financial expenditures by budget cost categories, as compared to the estimates in your most recent SBA-approved budget. Explain any cost overruns of 10% or more by budget cost category.

3. Compare what you actually achieved to the performance criteria and objectives presented in your application for the OA grant.

4. Present any other information you believe helpful to SBA in understanding and measuring your OA activities and accomplishments during the reporting period (may be attached).

5. If you requested from SBA and received an exception to the requirement to raise the full amount of grant matching resources before grant award (pursuant to 13 CFR 108.380(b)), discuss your progress toward raising the additional amount of grant matching resources required, and specifically any milestones met during the reporting period.

Certification

Operational Assistance (OA) Grant Performance Report

Recipient hereby certifies that the following is a list of all Smaller Enterprises that received Operational Assistance during the period beginning [ / / ] and ending [ / / ].

Smaller Enterprise Name		Amount/Value of OA provided during Period
		$
		$
		$
		$
		$
		$
Total Amount/Value of OA		$
Total number of Smaller Enterprises receiving OA
Total Amount/Value provided during Period as % of Total Grant Award Amount	%

Recipient further certifies that the information contained in this report filed with the SBA for this reporting period is complete and correct to the best of my knowledge and belief.

_________________________________________________

Name of Recipient

By: ___________________________________________

Signature of Authorized Official

___________________________________________

Name of Authorized Official (Print)

___________________________________________

Title (General Partner, Officer, or Managing Member)

Date ________________

SBA is collecting the information on this Operational Assistance (OA) Grant Performance Report in accordance with section 361 of the Small Business Investment Act (15 USC 689j) and paragraph 51 of Circular A-110 of the Office of Management and Budget, for the purposes of evaluating the Recipient's performance, especially as it relates to the performance goals that it proposed in its application for assistance under the NMVC program, and determining the extent of the social, economic, or community development impact of its activities under the grant. The information collected on this form is required in order for the NMVCC to continue to receive SBA assistance.

Please note: The estimated burden for completing this form is 2 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 Number 3245-0332. Please do not send forms to OMB.

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SBA Form 2219 (6/02)