Form SBA FORM 857 SBA FORM 857 Request for information concerning portfolio financing b

OMB Approval No. 3245-0109

Expiration Date:

U.S. SMALL BUSINESS ADMINISTRATION (SBA)

REQUEST FOR INFORMATION CONCERNING PORTFOLIO FINANCING

BY Small Business Investment Companies (SBICs)

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The information requested below obtains voluntary representations from the management of small businesses receiving financing from Small Business Investment Companies (SBICs) to assist in SBA’s oversight of the SBIC program. The information is collected by an SBA Examiner as part of an onsite examination to determine SBIC compliance with applicable statutory and regulatory program provisions, including, but not limited to: conflicts of interests, maximum interest rates, use of financing proceeds, and verification of information reported to SBA regarding financing activities. Confidential information will be protected from disclosure to the extent permitted by law, including Exemptions 4, 6, and 8 of the Freedom of Information Act, 5 U.S.C 552.

Please return completed forms within 10 days as directed by the requesting SBA Examiner.

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Name of SBIC_________________________ Name of Small Business_________________________

1. What are the terms and the unpaid balance of your company’s financing from the SBIC?

2. Does the SBIC own an equity interest in your company (shares of stock, partnership interest, etc.)?

Yes____ No____

If ‘Yes’ please indicate the number of shares, the percentage of ownership, and the purchase price paid for such equity interest:

3. Have any warrants, options, or any other forms of equity interest been issued by your company to the SBIC? Yes____ No____

If ‘Yes’ what are the terms and the conditions of these instruments, including dates, numbers of shares, prices, etc.?

4. How were the proceeds of this financing used by your company?

5. Are any of the officers, directors or owners of your company related to or affiliated in any way with:

1. The SBIC or its officers, directors or owners? Yes____ No____

2. Any other SBIC or its officers, directors or owners? Yes____ No____

3. If the answer to either question above is ‘Yes’ please furnish details:

SBA Form 857 (XX/XX) Previous Editions Obsolete

6. Who were the officers, directors and/or owners of your company at the time of the financing?

7. Any other comments or concerns you consider pertinent to SBA’s examination:

WARNING By signing below, you are acknowledging that a representative for the U.S. Small Business Administration (SBA) and the SBA are relying on this information, and that false statements can lead to criminal prosecution under 18 U.S.C. 1014, and other statutes, with fines of up to $1,000,000 and imprisonment of up to 30 years, and civil fraud damages of three times the Government’s loss.

I hereby certify that all information provided in this form is true and correct to the best of my knowledge. 

____________________________________________ _______________________________

SIGNATURE AND TITLE DATE

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Portfolio Company Name

SBA Form 857 (XX/XX) Previous Editions Obsolete

PLEASE NOTE: The estimated burden for completing this form is 1 hour. You are not required to respond to this or 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 3245-0109).

PLEASE DO NOT SEND FORMS TO OMB.