SBA Form 468.3 Annual Financial Report Corporate SBIC'S

SBA FORM 468

OMB Approval No. 3245-0063

(Partnership SBICs)

Expiration Date mm/dd/yyyy

SHORT FORM

Name of Licensee:
License Number:
Street Address:
City, State, and Zip Code :
County:
Employer ID Number:
For the Reporting Period Ending:

Months:

A- Fund Focus
B- Ownership

SBA Form 468 is to be completed only by small business investment companies (SBICs) licensed by the Small
Business Administration . This form contains financial statements and supplementary information which SBA
uses to evaluate an SBIC's financial condition and compliance with its business plan and SBIC program requirements.
SBA also pools financial information provided by individual SBICs to analyze the SBIC program as a whole with
respect to the risk of financial loss to the government and the impact of SBIC financings on the growth of small
business.
Form 468 must be completed and filed electronically in the SBIC-Web system. Within the system, you may also
upload supplemental documents as the form instructs.
SBIC-Web requires an SBA-approved user account. Submit your account request to sbicwebsupport@sba .gov.

Please Note: The estimated burden for completing this form is 23 hours 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, D.C. 20416
and/or SBA Desk Officer, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503 . PLEASE DO NOT

SEND FORMS TO OMB.

SBA Form 468.3 {02/14) Previous edition obsolete .

Page lP

Example Only- SBICs Must Use Web-Based System To Enter Form 468

STATEMENT OF FINANCIAL POSITION

OMB Approval No. 3245-0063

ASOF

Expiration Date mm/dd/yyyy

----------------------{Amounts rounded to nearest dollar)

Name of Licensee:

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License No.

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-

ASSETS

LOANS AND INVESTMENTS:

Unrealized

Unrealized

Reported

Cost

Depreciation

Appreciation

Value (1)

(Col. 1}

(Col. 2}

(Col. 3}

(Col. 4}

Portfolio Securities:

1
2
3
4

Loans
Debt Securities
Equity Securities
Total Portfolio Securities

Assets Acquired in Liquidation of Portfolio Sec;:u:.:...ri:.:ti:e:.:.
: s=::.______________________--r---------------r---------------,
5 Receivables from Sale of Assets Acquired
6 Assets Acquired
7 Total Assets Acquired

8 Operating Concerns Acquired
9 Notes and Other Securities Received

10 TOTAL LOANS AND INVESTMENTS
11 Less Current Maturities
12 Loans and Investments Net of Current Maturities
Investment in 301(d} Lric....:.e....:.
n.:...
se:...:e:....:(!.::2:.}t. . - - - - - - - - - - - - . .
13 Name/License No.

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CURRENT ASSETS
14 Cash and Cash Equiv aIents
15 Invested Idle Funds
16 Interest and Dividen ds Receivable
17 Notes and Accounts Receivable
18 Receivables from Pa rent or Other Associates
19 Less : Allowance for Losses {lines 16, 17, and 18)
20 Current Maturities o f Portfolio Securities
21 Current Maturities of Assets Acquired
22 Current Maturities o f Operating Concerns Acquired
23 Current Maturities o f Other Securities
24 Other (specify)

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25 Other (specify)

OTHER ASSETS
26 Net Furniture and Equipment
27 Net Leverage Fees
28 Other (specify)
29 Other (specify)

30 TOTAL ASSETS
(1) Column Headings apply to items 1 through 12 only. (Cost- Unrealized Depreciation+ Unrealized Appreciation= Value)
(2) Note to item 13 should include percent owned, cost basis and changes resulting from equity method of accounting.

SBA Form 468.3 (02/14) Previous edition obsolete .

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Example Only- SB/Cs Must Use Web-Based System To Enter Form 468

STATEMENT OF FINANCIAL POSITION
ASOF

-------------------(Amounts rounded to nearest dollar)

Name of Licensee :

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OMB Approval No. 3245-0063
Expiration Date mm/dd/yyyy

License No.

LIABILITIES AND CAPITAL

Liabilities
Long-Term Debt
31 Notes and Debentu res payable to or guaranteed by SBA.
32 Notes and Debentures Payable to Others
33 a. Participating Securities Held or Guaranteed by SBA
b. Earned Prioritized Payments Allocated for Distribution

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c. SBA Profit Participation Allocated for Distribution

Current Liabilities
34 Accounts Payable
35 Due to Parent or Other Associates
a. Management Exp enses Due to Associates
b. Other Due to Ass ociates
36. Accrued Interest Pa yable
37. Accrued Taxes Paya ble
38. Distributions Payab le
39. Short-term notes Pa yable/Lines of Credit

40 Other (specify)
41 Other (specify)

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Other Liabilities
42 Deferred Credits
43 Deferred Fee Income

44 Other (specify)

.-------------------------~

45 Total Liabilities
PARTNERS' CAPITAL
46 Private Partners' Contributed Capital
a. General Partner(s)
b. Limited Partner(s)

47 Other (specify)

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48 Unrealized Gains (Lo ss) on Secu rities Held
49 Non-Cash Gains/lnco me
50 Undistributed Net Re alized Earnings
51 Und istributed Realize d Earnings (line 49 plus line 50)

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52 TOTAL PARTNERS' CAPITAL
58 TOTAL LIABILITIES AND PARTNERS' CAPITAL
SBA Form 468.3 (02/14) Previous edition obsolete .

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Example Only- 58/Cs Must Use Web-Based System To Enter Form 468

STATEMENT OF OPERATIONS REALIZED
MONTHS ENDED _ _ __
For

OMB Approval No. 3245-0063
Expiration Date mm/dd/yyyy

(Amounts rounded to nearest dollar)
Name of Licensee:

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License No.

INVESTMENT INCOME
11nterest Income
2 Dividend Income
3 Income (Loss) from Investments in Partnerships/Flow-through Entities
4 Income (Loss) from Investments in Section 301(d) Licensee
5 Fees for Management Series
6 Application, Closing and Other Fees
7 Interest on Cash Equivalents and Invested Idle Funds
8 Income from Assets Acquired in Liquidation of
Loans and Investment (net of$ _ _ _ _ _ Expenses)
9 Other Income

10 GROSS INVESTMENT INCOME
EXPENSES
lllnterest Expense
a. Interest Expense-- Earned Prioritized Payments, Charges & Adjustments
b. Interest Expense -- SBA Debentures
c. Other Interest Expense
12 Commitment Fees & Other Financial Costs
13 Compensation and Benefits (Officer and Employee)
14 Investment Advisory and Management Services
15 Partners' Meetings
16 Appraisal and Investigation
17 Advertising, Communication and Travel
18 Cost of Space Occupied
19 Depreciation and Amortization
a. Amortization of Leverage Fees
b. Other Depreciation and Amortization

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20 Insurance
21 Payroll and Other Taxes
22 Provision for Losses on Receivables (excluding loans receivable)
23 Legal Fees
24 Audit and Examination Fees
25 Miscellaneor-us_E_x...:..p..:.e..:.ns_e_s_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _....,
a. Misc. #1
b. Misc. #2
c. Misc. #3
d. Misc. #4
e. Misc. #5
f. Misc. #6

26 TOTAL EXPENSES
27 NET INVESTMENT INCOME (LOSS)
28 NET REALIZED GAIN {LOSS) ON INVESTMENTS {1}
29 NET INCOME {LOSS} BEFORE NONRECURRING ITEMS
30 Extraordinary Item
31 Cumulative Effect of Change in Accounting Principle

32 NET INCOME (LOSS)
(1) Provide supporting detail for all realized gains and losses on Page 13P of this form.
SBA Form 468.3 (02/14) Previous edition obsolete.

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Example Only- SB/Cs Must Use Web-Based System To Enter Farm 468

STATEMENT OF CASH FLOWS
MONTHS ENDED _ _ __
For

OMB Approval No. 3245-0063
Expiration Date mm/dd/yyyy

(page 1 of 2)
(Amounts rounded to nearest dollar)
Name of Licensee :

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License No .

OPERATING ACTIVITIES
Cash Inflows
!Interest Received from Portfolio Concerns
2 Dividend Received from Portfolio Concerns
3 Other Income Received from Portfolio Concerns
4 Management Services and Other Fees Received
5 Interest on Cash Equivalents and Invested Idle Funds
6 Cash Received from Assets Acquired in Liquidation
7 Other Operating Cash Receipts
Cash Outflows
8 Interest Paid (excl. Earned Prioritized Payments, Charges and Adjustments)
9 Commitment Fees and Other Financial Costs
10 Investment Advisory and Management Fees
11 Partners' and Employees' Compensation and Benefits
12 Operating Expenditures (Excluding Compensation and Benefits)
13 Other Operating Cash Disbursements
14 NET CASH PROVIDED BY (USED IN) OPERATING ACTIVITIES

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INVESTING ACTIVITIES
Cash Inflows
15 Loan Principal Payments Received from Portfolio Concerns
16 Returns of Capital Received from Portfol io Concerns
17 Net Proceeds from Disposition of Portfolio Securities
18 Liquidation of ldleFr-u;;.;n.;.;d.;.; s. . :.l. . :.nv.:. . :e.;.; s. :.;tm. :. :. .:.e. . :.nt.;.; s_ _ _ _ _ _ _ _ _ _ _ _ _,
19 Other (Specify)
Cash Outflows
20 Purchase of Portfolio Securities
21 Loans to Portfolio concerns
22 Idle Funds Investment
~------------------,
23 Other (Specify)
24 NET CASH PROVIDED BY (USED IN) INVESTING ACTIVITIES

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FINANCING ACTIVITIES
Cash Inflows
25 Proceeds from Issuance of SBA-Guaranteed Debentures
25 Proceeds from Issuance of SBA-Guaranteed Partcipating Securities
27 Proceeds from Non-SBA Borrowing
28 Proceeds from Sale of Stock or Other Capital Contribution
29 Other (Specify)
Cash Outflows
30 SBA Leverage Fees
31 Principal Payments on SBA-Guaranteed Debentures
32 Principal Payments on Non-SBA Borrowing
33 Redemption of Participating Securities
34 Redemption of Private Partnership Interests
35 Prioritized Payments, Charges and Adjustments Paid
36 SBA Profit Participation Paid
37 Other Distributions Paid
r-------------------~
38 Other (Specify)
39 NET CASH PROVIDED BY (USED IN) FINANCING ACTIVITIES

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SBA Form 468 .3 (02/14) Previous edition obsolete .

Page SP

Example Only - SBICs Must Use Web-Based System To Enter Form 468

STATEMENT OF CASH FLOWS
MONTHS ENDED _ _ __
For

OMB Approval No. 3245-0063
Expiration Date mm/dd/yyyy

(page 2 of 2}
(Amounts rounded to nearest dollar)
Name of Licensee :

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Li cense No.

411NCREASE (DECREASE) IN CASH AND CASH EQUIVALENTS
42 CASH AND CASH EQUALENTS AT BEGINNING OF PERIOD
43 CASH AND CASH EQUIVALENTS AT END OF PERIOD (line 14, page 2P)

RECONCILIATION OF NET INCOME (LOSS) TO NET CASH PROVIDED BY (USED IN) OPERATING ACTIVITIES
44 Net Income (Loss) (Line 32, page 4P}

L - 1_ _ _ _ _ _ ,

Adjustments to Reconcile Net Income (Loss) to Net Cash Provided by (used in) Operating Activit,_ie.;..;s_: - - - - - - ,
45 Depreciation and Amortization (line 19, page 4P}
46 Provision for Losses on Accounts Receivable (line 22, page 4P}
47 Earned Prioritized Payments, Charges, and Adjustments
48 Realized (Gains) Losses on Investments (line 28, page 4P)
49 Other (Sp,,-e_c_ify:..:.)_.:::===========:::;--------:

a. ~--------------------------------~
b. r--------------~
c. ~--------------------------------~

§

Changes in Operating Assets and Liabilities Net of Noncash Items
50 (Increase) Decrease in Interest and Dividends Receivable
51 (Increase) Decrease in Other Current Assets
52 Increase (Decrease) in Accounts Payable
53 Increase (Decrease) in Accrued Interest Payable
54 Increase (Decrease) in Accrued Taxes Payable
55 Increase (Decrease) in Distributions Payable
56 Increase (Decrease) in Other Current Liabilities
57 Other (Specify)
58 Other (Specify)
59 NET CASH PROVIDED BY (USED IN} OPERATING ACTIVITIES
(Total must agree with line 14, page SP}

Supplemental disclsure of non-cash financing and investing activites may be required .
See ASC 230, "Statement of Cash Flows".

SBA Form 468 .3 (02/14) Previous edition obsolete.

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Example Only - 58/Cs Must Use Web-Based System To Enter Form 468

STATEMENT OF PARTNERS' CAPITAL

OMB Approval No. 3245-0063
Expiration Date mm/dd/yyyy

AS OF - - - - - - (page 1 of 2)
(Amounts rounded to nearest dollar)
Name of Licensee:

License No .
GENERAL

PART I. PRIVATE PARTNERS' CONTRIBUTED CAPITAL

PARTNER(S)

LIMITED PARTNER(S)

(page 3P, line 46a}

(page 3P, line 468}

TOTAL

NON-CASH
GAINS/INCOME

UNDISTRIBUTED NET
REALIZED EARNINGS

UNDISTRIBUTED
REALIZED EARNINGS

(1}

(2}

(1) + (2)

1 BALANCE AT BEGINNING OF PERIOD
2 ADDITIONS:
a. Partnership interests issued for cash
b. Partnership interests issued for services rendered
c. Partnership interests issued for contributed non-cash assets
d . Capitalization of Retained Earnings Available for Distribution
e. Other credits (specify) _ _ _ _ _ _ _ _ _ _ _ __
3 Total additions (sum of 2a through 2E)
4 Subtotal (line 1 plus line 3)
S DEDUCTIONS:
a. Liquidation of of Partnership interests
b. Other debits ( s p e c i f y ) - - - - - - - - - - - - 6 Total deductions (sum of Sa through Sb)
7 BALANCE AT END OF PERIOD (line 4 minus line G)-Total must agree with lines 46a and 46b, page 3P

PART II. UNDISTRIBUTED REALIZED EARNINGS
1 BALANCE AT BEGINNING OF PERIOD
2 ADDITIONS:
a. Net investment income
b. Interest Expense- Earned Prioritized Payments, Charges &
Adjustments (line lla, page4P)
c. Realized gain (loss) on investments
d. Gain on appreciation of securities distributed in kind
e. Other (specify) _ _ _ _ _ _ _ _ _ _ _ __
3 Total additions (sum of 2a through 2e)
4 Subtotal (line 1 plus line 3)
S DEDUCTIONS:
a. Cash Distributions
b. Distribtions allocated but not paid
c. In-Kind Distributions (at fair value)
d. Capitalization of Retained Earnings available for Distribution
e. Other (specify) _ _ _ _ _ _ _ _ _ _ _ __
6 Total deductions (sum of Sa through Se)
7 Total before collection of non-cash gains/income
(line 4 minus line 6}
8 Collection of non-cash gains/income

9 BALANCE AT END OF PERIOD (line 7 plus line 8)Totals must agree with lines 49, 50, and 51, page 3P

SBA Form 468.3 (02/14} Previous edition obsolete .

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Example Only- SBICs Must Use Web-Based System To Enter Form 468

I. RETAINED EARNINGS AVAILABLE FOR DISTRIBUTION
II. REGULATORY AND LEVERAGEABLE CAPITAL

OMB Approval No. 3245-0063
Expiration Date mm/dd/yyyy

AS OF - - - - - - (Amounts rounded to nearest dollar)
Name of Licensee :

I

License No .

PART I. RETAINED EARNINGS AVAILABLE FOR DISTRIBUTION OR CAPITALIZATION.
1 Undistributed net Realized Earnings (line 50, page 3P)
2 LESS : Unrealized Depreciation (line 10, column 2, page 2P)
3 RETAINED EARNINGS AVAILABLE FOR DISTRIBUTION OR CAPITALIZATION

PART II. SCHEDULE OF REGULATORY AND LEVERAGEABLE CAPITAL
1 Private Partners' Contributed Capital (line 46, page 3P)
2ADD :
a. Unfunded binding commitments from Institutional Investors
b. Waived management fees credited as capital contributions
3 LESS: Regulatory Distributions
a. Organization Expenses Not Approved by SBA (1)
b. Partnership interests Issued for Services
c. Partnership interests Issued for Non-cash Assets (unless approved by
SBA for inclusion in Regulatory Capital or converted to cash)
d. Other ( s p e c i f y ) - - - - - - - - - - - - 4 Total Regulatory Deductions (Sum of 3a through 3d)
5 Other Adjustments to Regulatory Capital (specify) _ _ _ __ _ _ _ _ _ _ _ __
6 REGULATORY CAPITAL (sum of lines 1, 2, 4, and 5)
7 LESS: Unfunded binding commitments from Institutional Investors
8 LESS : Non-cash assets included in Regulatory Capital, other than eligible investments in Sm all Concerns
9 LESS: Other deductions (specify) - - - - - - - - - - - - - - - - - - - 10 LEVERAGEABLE CAPITAL (sum of lines 6 through 9)

PART Ill. CUMULATIVE PRIVATE INVESTOR CAPITAL CONTRIBUTIONS & DISTRIBUTIONS

(for 58/Cs licensed on or after January 1, 1994}
1 All Private Capital Contributions Ever Paid-In
2 All Distributions to Private Investors Ever Paid Out- Including Fair Market Value of Non-Cash Distributions

NOTES
(1} Deduct only those organizational expenses which were not accepted as reasonable by SBA.

SBA Form 468.3 (02/14) Previous edition obsolete .

Page 8P

Example Only - SBICs Must Use Web-Based System Ta Enter Form 468

SCHEDULE OF COMMITMENTS
ASOF

OMB Approval No. 3245-0063
Expiration Date mm/dd/yyyy

Amount of
Name of Small Business

SBA Form 468.3 (02/14) Previous edition obsolete.

Emolover ID

Commitment

Date Made

Fvnir:~tinn

Date

Loan, Debt, or

New investment or

Equity?

follow-on?

Page 9P

Example Only- SBICs Must Use Web-Based System To Enter Form 468

SCHEDULE OF GUARANTEES

OMB Approval No. 3245-0063

ASOF

Name of Small Business I

mnlnv,.r

ID

SBA Form 468.3 (02/14) Previous edition obsolete .

Guarantee
Amount

Date
Made

Expiration Date mm/dd/yyyy

Expiration Date

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Name of Guaranteed
Pa

Is guarantee
collaterialized? If so, by
what?

Description of underlying
of Small Business

Page lOP

Example Only - SBICs Must Use Web-Based System To Enter Form 468

SCHEDULE 1

SCHEDULE OF LOANS AND INVESTMENTS

OMB Approval No. 3245-0063

ASOF

Expiration Date mm/dd/yyyy
License No.
Cost at End of Period

Loans and Investments {ordered bv date ascendinl!:l
1n1t1a1 mvest.
Investment Type
Amount
Investment Date

l.Ost at ISeg. or
Period

Other Notes:
:.mailer Enterprise?
Comments :

Qualifies as start-up per CFR 107.50?1
Equity Capital?!
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Eguit~ Information
Type of Shares:
Equity Features :

Number of Shares :
Market/Liquidity:

Warrants?
~erms :

-

Expiration Date:

Other type of OL Asset? __ If yes:

Aaaltlonst
Deductions

uescr1pt1on or
Addition/Deduction

SBA Form 468.3 (02/14) Previous edition obsolete .

l.ost at tna or
Period

unreanzea App
(Dep)

Total Reported Value

Reported Value

Class I and II AI;H!reciation
Class I Appreciation Amount:
Class II Appreciation Amount:
If Class II, Date of Up Round?
Loan£Debt Information
Maturity Date :
Repay. Terms :
Collateral:
Date of Last Payment:
Balloon Payment Due:

Type :
Amount:

Unrealized App (Dep)

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Description of Asset:
Description of Liens:

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Type :

Status :
Interest Rate :

Balloon %at maturity:
Future Estimated Recoveries:
Date Investment Concluded:

Page llP-2

Example Only- SBICs Must Use Web-Based System To Enter Form 468

SCHEDULE 1 A/B

1 A. SUMMARY OF LOANS AND INVESTMENTS

OMB Approval No. 3245-0063

1 B. SMALLER ENTERPRISE FINANCING$

Expiration Date mm/dd/yyyy

ASOF
Name of Licensee:

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License No.

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1 A. SUMMARY OF LOANS AND INVESTMENTS
1

2

3

4

5

Cost at Beginning of

Additions/

Cost at End of

Appreciation

Period

(Deductions)

Period

(Depreciation)

6

Unrealized
Investment Category

Reported Value

Total Loans (line1, page 2P)

'

Total Debt Securities (line 2, page 2P)
Total Equity Securities (line 3, page 2P)
Total Portfolio Securities (line 4, page 2P)
Total Assets Acquired (line 7, page 2P)
Total Operating Concerns Acquired (line 8, page 2P)
Total Notes and Other Sees. Received (line 9, page 2P)
Total Loans and Investments (line 10, page 2P)

1 B. SMALLER ENTERPRISE FINANCINGS
1 Cumulative dollar amount of Smaller Enterprise Financings extended between April 25, 1994 and close of reporting fiscal year.

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2 Cumulative dollar amount of all Financing extended between April 25, 1994 and close of reporting fiscal year.

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3 Percentage of total Financings extended to Smaller Enterprises (line 1 divided by line 2)

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SEE 13 CFR 107.710 FOR PERCENTAGE OF TOTAL FINANCINGS WHICH MUST BE IN SMALLER ENTERPRISES.

SBA Form 468.3 (02/14) Previous edition obsolete.

Page 12P

Example Only· SB/Cs Must Use Web-Based System To Enter Form 468

SCHEDULE 2

SCHEDULE OF REALIZED GAINS AND

OMB Approval No. 3245-0063

LOSSES ON LOANS AND INVESTMENTS

Expiration Date mm/dd/yyyy

FOR

MONTHS ENDED

Name

Name of Small Business I Employer

Security

ID

'----

!Transaction Type
I Date

/

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Net Sales
Price

Name
Purchaser (applies to sales and

Realized
Cost

Cash

__
Escrow Exp. Comments

(1) Security Type: L= Loans, D=Debt, E=Equity, AA=Assets Acquired, OC=Operating concerns acquired, NS=Notes and Other Securities Received
(2) Transaction Type: S= Sale, E=Exchange, C=Charge-off, D=Distribution of Securities
SBA Form 468.3 (02114) Previous edition obsolete.

Page 13P

Example Only - SBICs Must Use Web-Based System To Enter Form 468

SCHEDULE 4

SCHEDULE OF DELINQUENT

OMB Approval No. 3245-0063

LOANS AND INVESTMENTS

Expiration Date mm/dd/yyyy

ASOF

Interest
Name of Small Business I
ID

Outstanding
PrinciDal Balance

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Amount Past
Due

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Days Past
Due Ill

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Amount
Past Due

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Days Past
Due

Date of Last Pavml"nt

Interest

Amount of Last Pavml"nt

Interest

Fair Makrket
Value OF
Collateral

(1) Based on oldest delinquency.
SBA Form 468.3 (02/14) Previous edit ion obsolete .

Page lSP

Example Only- SBICs Must Use Web-Based System To Enter Farm 468

SCHEDULE 5

SCHEDULE OF CASH AND INVESTED IDLE FUNDS

OMB Approval No. 3245-0063

ASOF

Expiration Date mm/dd/yyyy
License No.

Name of Licensee :

COMPLETE SCHEDULE ONLY IF LICENSEE HAS, OR PLANS TO APPLY FOR, SBA LEVERAGE.

I. U.S. GOVERNMENT OBLIGATIONS (direct or guaranteed)

Description

Maturity Date

Amount

Maturity Date

Amount

II. REPURCHASE AGREEMENTS WITH FEDERALLY-INSURED INSTITUTION

Name and Location of Financial Institution

Ill. CERTIFICATES OF DEPOSIT ISSUED BY FEDERALLY-INSURED INSTITUTIONS

Name and Location of Financial Institution

Maturity Date

Amount

IV. DEMAND DEPOSIT, MONEY MARKET, AND SAVING ACCOUNTS IN FEDERALLY-INSURED INSTITUTIONS

Name and Location of Financial Institution

Maturity Date

Amount

Maturity Date

Amount

V. OTHER CASH AND INVESTED IDLE FUNDS

Description

TOTAL CASH, CASH EQUIVALENTS AND IDLE FUNDS.___ _ _ _ _ _ _ ___,
(total must agree with sum of lines 14 and 15, page 2P)

SBA Form 468 .3 (02/14) Previous edition obsolete .

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Example Only - SBICs Must Use Web-Based System Ta Enter Farm 468

SCHEDULE 8

Unaudited Portfolio Company Information

OMB Approval No. 3245-0063

ASOF

Expiration Date mm/dd/yyyy
License No.
Cost at End of Period

Unrealized App (Dep)

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Total Reported

panv
Business Description

1st Date Invested:
Current stage:

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Exchange:! -

NAICS:

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Overline?

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'f'

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,l

Ad,,..

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As of Date ~------------~--------------~------------~
Basis Period
-

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Stock Symbol:!~

If orignal investment company's name changed, was acquired/merged,
company name of original investment:

City/State:
Zip Code:

Rounded to nearest$

....

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LMI:

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'f'

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Other Comments:
_

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Portfolio Company Waterfall/Capitalization Table

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Going Concern

_

Other

State Taxes Paid:

PDF File Uploaded:

Instructions: Upload latest waterfall/capitalization table in PDF format if you hold an equity investment in the portfolio company or you hold warrants that you have valued over cost. If the
portfolio company is public and you only hold debt securities or common stock, you do not need to provide this information.
Include all relevant information associated with each security, including information needed to assess value of your holdings. Relevant information may include : date closed, security issued,
price, total round size, SBIC's participation within round, if available and not confidential name of significant investors (over 10% ownership in security), liquidation preferences, seniority,
accruing dividends, etc ... If the SBIC has been transferred to the Office of Liquidation, you must also describe any investor rights you hold, such as negative covenants, board membership or
observation rights, or other rights (such as veto or springing) .

SBA Form 468.3 (02/14) Previous edition obsolete.

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Example Only- 58/Cs Must Use Web-Based System To Enter Form 468

SCHEDULE 9

UNAUDITED SBIC CUMULATIVE INVESTMENT

OMB Approval No. 3245-0063

PERFORMANCE

Expiration Date mm/dd/yyyy

ASOF
License No.

Name of Licensee:

Include all investments, both realized and unrealized, made by the SBIC since the fund commencement date or October 1, 1993, whichever is later. If historical information is unavailable in the
tormat requested, you may omit {1) investments realized or written off on or before June 30, 2011, and (2) for investments held as of July 1, 2011, gross receipts received on or before June 30,
2011.
10
11
1
4
7
9
2
3
6
8
Gross Receipts*
Gross Receipts to
Name of Small Business

Employer ID

Date 1st
Invested

Total Dollars
Invested

TOTAL

* Note:

Cash

Equity

Total

SBA Reported
Value

Total Dollars
Invested

(Gross Receipts+ Reported
Value) to Total Dollars
Invested

--

Gross Receipts includes all cash and qualifying equity securities received by SBIC for portfolio company investment. Cash receipts may include interest, dividends, repayment of debt, profit

distributions, etc ... Equity securities may only be included if they have been distributed by the SBIC to its investors; in which case, they should be entered based on the distribu.ted value . Equity
securities or notes still held by the SBIC should be included in the Residual Value .

SBA Form 468.3 (02/14) Previous edition obsolete .

Page 21P

- - -- - -- - - -- - - -- - - - - --

QUARTERLY CERTIFICATIONS

~

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OMB Approval No. 3245-0063
Expiration Date mm/dd/yyyy

Name of Licensee:

I

License No.

MANAGEMENT CERTIFICATION
1,[
[

(Licensee),)
the General Partner of

a General Partner of
a General Partner of
(Licensee),:

[

a Managing Member of

the General Partner of

(Licensee),]

[

the President of

the General Partner of

(Licensee),] do hereby certify as follows:

1. The Financial Report for the_ months ended
submitted by
(Licensee) to the Small Business Administration on SBA Form 468 is true and correct in all
respects. The statements and schedules listed below have been omitted from the submission.
2. The General Partner of
of such company for the _

(Licensee) has reviewed and approved the Financial Report

months ended

3.

(Licensee) is in good standing under the laws of the State of

STATEMENTS AND SCHEDULES OMITIED :

CAUTION: By signing below, you are certifying as to the truth and accuracy of the Financial Report in all respects, and
acknowledging that officials in the Small Business Administration (SBA) will be relying on this certification. Knowingly making
a false statement to or concealing a material fact from the SBA can lead to imprisonment of up to 30 years and/or a fine of up
to $1,000,000 under 18 U.S.C. § 1014.
By:
Name:
Date:

SBA Form 468.3 (02/14) Previous edition obsolete .

Title :

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