Form SBA Form 1031 SBA Form 1031 Portfolio Financinhg Report

U.S. Small Business Administration Portfolio Financing Report

OMB No. 3245-0078 Expiration Date XX/XX/2017

Name of Licensee___________________________________

License Number___________

Part A - Small Business Concern Data

1. Name of Small Business ___________________________________ 2. Employer Identification Number ____-____________

3. Street Address _________________________________________________________________________________

4. City_________________________ 5. State______ 6. ZIP Code _________ 7. County __________________________

8. Small Business FAX __________________________ 9. Contact Person for FAX _______________________________

10. Date Business Established __/__/__ 11. Form of Business ____ 1) Corporation 2) Partnership 3) Proprietor 4) LLC

12a. NAICS Code ______________ Industry __________________________________________

12b. Energy Saving Qualified Investment? ____ If checked, was Energy Saving debenture used to finance investment? _____

13. Percentage of Small Concern (if any) Owned by:

American Indian or Alaska Native: ____% Asian: ____%

Black or African American: ____% Hispanic or Latino: ____% Native Hawaiian or Other Pacific Islander: ____% White: ____%

14a. Percentage of Small Concern Owned by Women (if any) _____%

14b. Percentage Owned by Veterans (if any) _______%

15. CEO or President (may select one or more):

Woman:____ American Indian or Alaska Native: ____ Asian: ____

Black or African American: ____ Hispanic or Latino: ____ Native Hawaiian or Other Pacific Islander: ____ White: ____

Part B - Prefinancing Information

16. Prefinancing Status: ____ (1) New Information (2) Previously Submitted (3) Acquired Business (4) New Business

17a. Stage of Company at Financing:________________

17b. Technology developed with SBIR/STTR funding:_____________

18. Small Business Concern’s Pre-Money Valuation: ___________________________

19. Fiscal Year End Immediately Prior to Date of Financing (Month/Day/Year) _____/_____/_____

20. Gross Revenue for Prior Fiscal Year $______________

21. After-Tax Profit or (Loss) for Prior Fiscal Year $____________

22. Income Taxes for Prior Fiscal Year: Federal $_________________ State $_________________ Local $________________

23. Net Worth $______________

24. Number of Employees _________

Part C - Financing Information

25. a. Date of Financing ___/___/____

b. Date of Disbursement ___/___/____

26. Did Licensee lead this investment? _____

27. Purpose of Financing (Percentage of Financing that will be used to support each category below. Percentages should total to 100%.)

a. Working Capital or Inventory Purchase b. Plant Modernization or Leasehold Improvement c. Acquisition of All or Part of an Existing Business d. Consolidation of Obligations or Non-SBIC Debt Refunding e. New Building or Plant Construction

____ ____ ____ ____ ____

f. Acquisition of Machinery and Equipment g. Land Acquisition or Dwelling Construction h. Marketing Activities i. Research and Development j. Other

____ ____ ____ ____ ____

28. Is this the first Financing of this Small Business by the Licensee? _______

29. Financing Instruments and Applicable Amounts (for participations, include Licensee's portion only):

Instrument

Amount

Initial Interest Rate(s)

% Actual Ownership

Loan Only

$__________

__________%

Debt with Equity Features

$__________

__________%

Equity Only

$__________

__________%

Total Licensee Financing

$__________

30. Total Size of Financing Round for Small Business Concern: _________________________

31. Comments:

Part D - Transmission Verification

Transmission Date _____/_____/_____

SBA Form 1031 (3/14) Previous Editions Obsolete

	U.S. Small Business Administration Portfolio Financing Report	OMB No. 3245-0078 Expiration Date XX/XX/2017
Use of Information: SBA Form 1031 is to be completed only by small business investment companies (SBICs) licensed by the Small Business Administration (SBA). This form contains Portfolio Concern financing and supplementary information that SBA uses to evaluate an SBIC's investment activities and compliance with SBIC program requirements. SBA also pools information provided by individual SBICs to analyze the SBIC program as a whole and the impact of SBIC financings on the growth of small business. Instructions for Submitting Completed Form: SBA Form 1031 must be completed and filed electronically in the SBIC-Web system. SBIC-Web requires an SBA-approved user account. Submit your account request to [email protected]. PLEASE NOTE: The estimated burden for completing this form is 12 minutes per response. You will not be required to respond to this information collection if a valid OMB approval number is not displayed. 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 SBA Desk Officer, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, DC 20503. PLEASE DO NOT SEND FORMS TO OMB.

SBA Form 1031 (3/14) Previous Editions Obsolete