Sba Form 856a Disclosure Statement Non-leveraged Licensees

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OMB CONTROL NO. 3245-0118

EXPIRATION DATE 02/28/09

U.S. SMALL BUSINESS ADMINISTRATION

DISCLOSURE STATEMENT

NON-LEVERAGED LICENSEES

TO: SBA EXAMINER

In connection with your examination of _______________________________________, as of _______________________, I represent that to the best of my knowledge and belief: (Write “None” where applicable.)

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1. No litigation was in progress or pending, or is now in progress or pending, except for the following:

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2. The licensee has not provided financings to any concerns which have also received financing from Associates (as defined in 13 CFR Section 107.50) except for the following:

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3. The licensee or its Associates provided management consultant services or technical services to the following portfolio companies:

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4. The licensee or its Associates assumed control over the following portfolio companies:

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5. The licensee’s Associates are also officers, directors, or employees (or partners) of portfolio companies as follows:

NAME OF PORTFOLIO COMPANY	NAME OF ASSOCIATE	POSITION IN PORTFOLIO COMPANY	DATE POSITION TAKEN

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SBA FORM 856a (9/01) REF SOP 90 35 PREVIOUS EDITIONS ARE OBSOLETE

6. The licensee’s Associates have direct or indirect financial interest in portfolio companies as follows:

NAME OF PORTFOLIO COMPANY AND DISCRIPTION OF FINANCIAL INTEREST, STOCK OWNERSHIP, WARRANTS, PARTNERSHIP INTEREST, LOAN, ETC.	DATE FINANCIAL INTEREST ACQUIRED	COST BASIS	NAME OF ASSOCIATE

7. The licensee’s Associates received title to or use of (with or without financial consideration) assets from portfolio companies or from the licensee as follows:

______________________________________ _____________________________

SIGNATURE AND TITLE DATE

PLEASE NOTE: The estimated burden for completing this form is 15 minutes per response. You are not required to respond to any collection of information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to U.S. Small Business Administration, Chief, AIB, 409 3^rd St., S.W., Washington, D.C. 20416 and Desk Officer for the Small Business Administration, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503. OMB Approval (3245-0118). PLEASE DO NOT SEND FORMS TO OMB.