Sba Form 468 Schedules

N

OMB No: 3245-0332

Exp. Date:

EW 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

SBA Form 468

Schedule 9

Social, Economic, or Community Economic Development Impact Assessment

Instructions: New Markets Venture Capital Companies (NMVCCs) must file this Schedule 9 of SBA Form 468 for each Financing the NMVCC makes. (See 13 CFR 108.630(e).) File this Schedule 9 with SBA annually, together with the remainder of SBA Form 468, as required in 13 CFR 108.630.

NMVCC

NMVCC Name

NMVCC #

Portfolio Concern

Business name							EIN #
Street Address
City			State		Zip		County
Contact Person							Phone

Low-Income Geographic Area (LI Area) in which Concern’s Principal Office is located (i.e., census tract number or specific qualifying criteria; or attach a print-out of search result from SBA’s web site at http://www.sba.gov/INV/NMVC/):

THE INFORMATION COLLECTED ON THIS FORM WILL BE KEPT CONFIDENTIAL

TO THE EXTENT PERMITTED BY APPLICABLE LAW.

Please indicate the start and end dates of the Portfolio Concern’s most recent fiscal year, using the following format (MM/DD/YY):

Fiscal year start date:	Fiscal year end date:

I. EMPLOYMENT INFORMATION

1. a. How many employees reside in a Low-Income Geographic Area? (An employee resides in a Low-Income Geographic Area is the zip code of the employee’s residence as reported on the IRS Form W-2 at the end of the tax year, falls within such an area. Use geographic mapping/searching page on SBA’s web site at http://www.sba.gov/INV/NMVC/ to look up whether a zip code falls within such an area.)

Enter amount:

2. What percentage of employees reside in a LI Area?

Enter Percentage:

c. List the number of full-time employees by wage category:

Annual Income from Wage/Salary	Number of Employees	Total Amount of Wage/Salary
$25,000 and below
$25,000 to $50,000
over $50,000
Totals:

2. Did the Portfolio Concern offer medical coverage of any kind or payment in lieu of medical coverage at the end of the most recent fiscal year?

Yes _____ No _____

Percentage of portfolio concern’s workforce:

3. At the end of the most recent fiscal year, did the Portfolio Concern offer pension plan (other than Social Security), savings plan, or 401K plan or the equivalent to full-time employees?

Yes _____ No _____

Percentage of portfolio concern’s workforce:

II. FINANCIAL INFORMATION

4. Ownership of the Portfolio Concern:

a. How much of the Portfolio Concern’s equity is owned by residents of LI Areas? _________%

b. What is the book value of that ownership at the end of the most recent fiscal year? $_____________

NOTE: FOR QUESTION 5, PLEASE USE “N/A” WHEN NOT APPLICABLE OR “0” WHEN THE AMOUNT IS ZERO

5. What were the total amounts of the following taxes the Portfolio Concern paid during the most recent fiscal year?

a. What was the real estate tax paid on business-related property during the most recent fiscal year? $________________

b. What was the property tax (on business equipment, inventory, etc.) paid during the most recent fiscal year? $________________

6. How much financing did the Portfolio Concern receive from all sources during the most recent fiscal year?

1. Equity capital from NMVC Companies $________________

2. Other equity $________________

3. Bank loans $________________

4. Other loans $________________

5. Line of credit $________________

6. Total financing $________________

SBA is collecting the information on this Schedule 9 of SBA Form 468 in accordance with section 361 of the Small Business Investment Act (15 USC 689j) for the purpose of determining the extent of the social, economic, or community development impact of the Financing. 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 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 Number 3245-0332. Please do not send forms to OMB.

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SBA Form 468, Schedule 9 (7/02) Previous edition obsolete