Form SBA Form 1941A SBA Form 1941A Financing Eligibility Statement - Social Disadvantage Fo

OMB Control No. 3245-0301 Expiration Date 01/31/2014

FINANCING ELIGIBILITY STATEMENT - "SOCIAL DISADVANTAGE"

(FOR INDIVIDUALS WHO ARE MEMBERS OF A DESIGNATED GROUP)

Individual's Name__________________________________________________

Applicant Business Name____________________________________________

INSTRUCTIONS:

The information requested below will be used by SBA to determine your personal eligibility for your business to receive financing under Section 301(d) of the Small Business Investment Act. Under this provision, to be eligible to receive financing, you must meet the criteria stipulated in Appendix 1 of this form. Please provide complete responses to each question. When your answers require additional space, use plain white paper properly identifying the item number to which you are responding. Omission of any information requested will result in a delay in the review and consideration of your application. 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.

I. SOCIAL DISADVANTAGE

A. I am claiming social disadvantage because of my identification as a:

____ Black American

____ Hispanic American

____ Native American (Alaska Natives, Native Hawaiians, or enrolled members of a Federally or State recognized Indian Tribe)

____ Asian Pacific American [An individual with origins from Burma, Thailand, Malaysia, Indonesia, Singapore, Brunei, Japan, China (including Hong Kong), Taiwan, Laos, Cambodia (Kampuchea), Vietnam, Korea, The Philippines, U. S. Trust Territory of the Pacific Islands (Republic of Palau), Republic of the Marshall Islands, Federated States of Micronesia, The Commonwealth of the Northern Mariana Islands, Guam, Samoa, Macao, Fiji, Tonga, Kiribati, Tuvalu, or Nauru]

____ Subcontinent Asian American (An Individual with origins from India, Pakistan, Bangladesh, Sri Lanka, Bhutan, the Maldives Islands or Nepal)

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II. Ownership and Control

A. Describe how socially or economically disadvantaged persons have a majority voting interest on the board of directors or any other governing body of the concern being financed (provide supporting documentation).

B. If your business is a corporation or a general partnership, explain how the eligible disadvantaged person(s) will own more than 50% of the voting interest of the business after receiving financing from the Small Business Investment Company (provide supporting documentation).

C. Is the business concern a limited partnership? ____ Yes ____ No

If Yes, explain (and provide documentation) to show whether the eligible disadvantaged person(s) are either the general partners, or that they control any corporate general partners

D. Indicate the percentage of the economic interest that eligible disadvantaged person(s) hold in the business (provide supporting documentation). (Economic interest is the right to proportionate distributions after all secured and unsecured debts have been satisfied.)

E. Do the eligible disadvantaged person(s) hold less than 50% of the economic interest in the company? If so, fully describe all other investors holding an economic interest in the company.

F. Does the eligible disadvantaged person(s) hold the highest officer position(s) in the company and manage the company on a full time basis?

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III. CERTIFICATION OF ELIGIBILITY

I hereby certify that all information in this Statement, including exhibits and supporting documentation, is true and complete to the best of my knowledge and is submitted for consideration of financing from an entity licensed by the U.S. Small Business Administration.

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.

_________________________________________

Name of Business

_________________________________________

Typed Name and Title of Qualifying Person

_________________________________________

Signature of Qualifying Person

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IV. LICENSEE CERTIFICATION

I hereby certify that the licensee has reviewed all information provided by the small business concern in support of its application for financing, and determined that all documentation and other information supports the eligibility of the applicant and establishes that the concern is owned and managed by an eligible socially or economically disadvantaged person(s), as defined in the Small Business Investment Act and more fully described in Appendix 1 of this form.

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.

_________________________________________

Name of SBIC/SSBIC

_________________________________________

Typed Name of President or General Partner

_________________________________________

Signature of President or General Partner

PLEASE NOTE: The estimated burden for completing this form is 2 hours. 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 3245-0301).

PLEASE DO NOT SEND FORMS TO OMB.

Appendix 1 to SBA Forms 1941A/B/C

DETERMINATION OF “DISADVANTAGED BUSINESS” BY SECTION 301(d) LICENSEES

(for additional background information, see SBA Policy and Procedural Release #2017,

dated June 22, 1994, available from SBA’s Office of Investment and Innovation)

STATEMENT OF POLICY

A Disadvantaged Business is a small business concern which is at least 50 percent owned, and controlled and managed by socially or economically disadvantaged individuals. No assistance may be provided by Section 301(d) Licensees to small business concerns unless such concerns are socially or economically disadvantaged (see the defined terms “Disadvantaged Business” and “Section 301(d) Licensee” in 13 CFR 107.50).

MEANING OF SOCIALLY OR ECONOMICALLY DISADVANTAGED

Except to recommend the elimination of any suggestion that only members of minority groups are eligible for assistance under this program and to specify that the program is to aid all who are hampered in achieving full citizenship in our economic system by virtue of their social or economic disadvantages, Congress has not fully defined the words “socially or economically disadvantaged.” This lack of precise legislative definition suggests that precise definition is inappropriate, and that flexibility is warranted.

PROCEDURES RELATING TO ELIGIBILITY DETERMINATIONS OF DISADVANTAGED BUSINESSES

If the business owner is a member of a designated group specified in CFR 13 Section 124.103 (i.e., Black Americans, Hispanic Americans, Native Americans, Asian Pacific Americans, and Subcontinent Asian Americans), then he/she may be assumed to be socially disadvantaged, and no further information (including the financial status of the owner) need be considered.

In determining whether other owners of small business concerns are socially or economically disadvantaged, reliance should not be placed upon a single factor, but on a composite of such factors as the social or economic background of the principal owners, controlling individuals and managers of the concern, along with the general pattern of their life, opportunities and education which have prevented them from obtaining financial or other assistance available to the average entrepreneur in the economic mainstream. Consideration may be given to such factors as contribute to a disadvantaged condition in the ordinary (dictionary) meaning of that word – lacking in basic resources or conditions necessary to an equal position in society.

SBA Form 1941A (4-95)