SBA Form 413 WOSB Personal Financial Statement Women Owned Small Business

OMB APPROVAL NO.: 3245-0188
EXPIRATION DATE: 09/30/20XX
PERSONAL FINANCIAL STATEMENT
WOMEN OWNED SMALL BUSINESS (WOSB) PROGRAM
U.S. SMALL BUSINESS ADMINISTRATION
This form must be completed by each individual claiming economic disadvantage in connection with the SBA’s Women-Owned Small Business (WOSB) Program. A
separate form must be completed by the individual’s spouse, unless the individual and the spouse are legally separated. Use attachments if necessary. Each attachment
must be identified as a part of this statement and signed. In addition, each individual claiming economic disadvantage must update the form as changes arise, but at least
annually, to ensure the information is current, accurate and complete.
SBA’s regulations state that to be considered economically disadvantaged for purposes of the WOSB Program, a woman must have an adjusted gross income averaged
over the three prior fiscal years of $350,000 or less; less than $6 million in the fair market value of all her assets (to include her primary residence and value of the
business concern); and less than $750,000 in personal net worth (excluding equity interest in her personal residence and ownership interest in the business, and funds
invested in a retirement account that are unavailable until retirement age). 13 C.F.R. §127.203.
Forms must be uploaded to the WOSB Program Repository. For more information on the WOSB program and the repository,
visit http://www.sba.gov/content/women-owned-small-business-program.

Name:

Business Phone:

Business Name and Address:

Other Phone:

City, State, & Zip Code:
The Information is current as of [month/day/year]:
Business Type:

__________Corporation

_________S Corp.

________LLC

______Partnership

_____ Sole Proprietor

Married: ______Yes _____No

ASSETS

(Omit Cents)

LIABILITIES

(Omit Cents)

Cash on Hand & in banks…………………………$ ________________
Savings Accounts…………………………………..$ ________________
IRA or Other Retirement Account………………...$ ________________
(Describe in Section 5)
Accounts & Notes Receivable…………………….$ ________________
(Describe in Section 5)
Life Insurance – Cash Surrender Value Only……$ ________________
(Describe in Section 8)
Stocks and Bonds…………………………………..$ ________________
(Describe in Section 3)
Real Estate…………………………………………..$ ________________
(Describe in Section 4)
Automobiles…………………………………………$ ________________
(Describe in Section 5, and include
Year/Make/Model)
Other Personal Property……………………………$ ________________
(Describe in Section 5)
Other Assets………………………………………….$ _______________
(Describe in Section 5)
Total
$ ________________

Accounts Payable……………………………$ ______________
Notes Payable to Banks and Others……….$ ______________
(Describe in Section 2)
Installment Account (Auto)…………………..$ ______________
Mo. Payments
$ ___________
Installment Account (Other)………………....$ ______________
Mo. Payments
$ ___________
Loan(s) Against Life Insurance……………...$ ______________
Mortgages on Real Estate…………………...$ ______________
(Describe in Section 4)
Unpaid Taxes………………………………….$ _____________
(Describe in Section 6)
Other Liabilities………………………………..$ _____________
(Describe in Section 7)
Total Liabilities………………………………....$ _____________
Net Worth……………………………………….$ _____________

Section 1.

Contingent Liabilities

Source of Income.

Salary………………………………………………….$ ________________
Net Investment Income……………………………...$ ________________
Real Estate Income………………………………….$ ________________
Other Income (Describe below)*…………………...$ ________________

Total
$ _____________
*Must equal total in assets column.

As Endorser or Co-Maker…………………….$ _____________
Legal Claims & Judgments…………………..$ _____________
Provision for Federal Income Tax…………....$_____________
Other Special Debt…………………………….$ _____________

Description of Other Income in Section 1.

*Alimony or child support payments should not be disclosed in “Other Income” unless it is desired to have such payments counted toward total income.

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Section 2. Notes Payable to Banks and Others. (Use attachments if necessary. Each attachment must be identified as part of this statement and signed.)
Names and Addresses of
Noteholder(s)

Original
Balance

Current
Balance

Payment
Amount

Frequency
(monthly, etc.)

How Secured or Endorsed
Type of Collateral

Section 3. Stocks and Bonds. (Use attachments if necessary. Each attachment must be identified as part of this statement and signed.)
Number of Shares

Name of Securities

Cost

Market Value
Quotation/Exchange

Date of
Quotation/Exchange

Total Value

Section 4. Real Estate Owned. (List each parcel separately. Use attachment if necessary. Each attachment must be identified as a part of this statement
and signed.)

Property A

Property B

Property C

Type of Real Estate (e.g.
Primary Residence, Other
Residence, Rental Property,
Land, etc.)
Address
Date Purchased
Original Cost
Present Market Value
Name & Address of
Mortgage Holder
Mortgage Account Number
Mortgage Balance
Amount of Payment per
Month/Year
Status of Mortgage
Section 5. Other Personal Property and Other Assets. (Describe, and, if any is pledged as security, state name and address of lien
holder, amount of lien, terms of payment and, if delinquent, describe delinquency.)

Section 6. Unpaid Taxes. (Describe in detail as to type, to whom payable, when due, amount, and to what property, if any, a tax
lien attaches.)

Section 7. Other Liabilities. (Describe in detail.)

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Section 8. Life Insurance Held. (Give face amount and cash surrender value of policies – name of insurance company and
Beneficiaries.)

I authorize the SBA to make inquiries as necessary to verify the accuracy of the statements made and to determine my economic
status.
CERTIFICATION: (to be completed by each person submitting the information requested on this form)
By signing this form, I certify under penalty of criminal prosecution that all information on this form and any additional supporting
information submitted with this form is true and complete to the best of my knowledge. I understand that SBA will rely on this
information when making decisions regarding eligibility for SBA’s Women-Owned Small Business Program. I further certify that I
have read the attached statements required by law and executive order.
Signature ________________________________________

Date

____________________

Print Name _______________________________________

NOTICE TO BUSINESSES IN THE WOSB PROGRAM:
CRIMINAL PENALITIES AND ADMINISTRATIVE REMEDIES FOR FALSE STATEMENTS:
Any person who misrepresents a business concern’s status as a WOSB or EDWOSB, or makes any other false statement in order to
influence the WOSB Program eligibility determination or other review process in any way (e.g., protest), shall be: (1) subject to fines
and imprisonment of up to 5 years, or both, as stated in Title 18 U.S.C. § 1001; (2) subject to fines of up to $500,000 or imprisonment
of up to 10 years, or both, as stated in Title 15 U.S.C. § 645; (3) subject to civil and administrative remedies, including suspension and
debarment; and (4) ineligible for participation in programs conducted under the authority of the Small Business Act.

PLEASE NOTE:

The estimated average burden hours for the completion of this form is 1.5 hours per response. If you have questions or comments concerning this estimate or any other aspect of this
information, please contact Chief, Administrative Branch, U.S. Small Business Administration, Washington, D.C. 20416, and Clearance officer, paper Reduction Project (3245-0188), Office
of Management and Budget, Washington, D.C. 20503. PLEASE DO NOT SEND FORMS TO OMB.

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PLEASE READ, DETACH, AND RETAIN FOR YOUR RECORDS
STATEMENTS REQUIRED BY LAW AND EXECUTIVE ORDER
Privacy Act (5 U.S.C. 552a)
The Privacy Act authorizes SBA to make certain “routine uses” of information protected by that Act. One such routine
use is the disclosure of information maintained in SBA’s investigative files system of records when this information
indicates a violation or potential violation of law, whether civil, criminal, or administrative in nature. Specifically, SBA
may refer the information to the appropriate agency, whether Federal, State, local or foreign, charged with responsibility
for, or otherwise involved in investigation, prosecution, enforcement or prevention of such violations. Another routine use
is disclosure to other Federal agencies conducting background checks; only to the extent the information is relevant to the
requesting agencies' function. See, 74 F.R. 14890 (2009), and as amended from time to time for additional background
and other routine uses.
Freedom of Information Act (5 U.S.C. 552)
This law provides, with some exceptions, that SBA must supply information reflected in agency files and records to a
person requesting it. Proprietary data on a small business would not routinely be made available to third parties. All
requests under this Act are to be addressed to the nearest SBA office and be identified as a Freedom of Information
request.
Executive Order 12549, Debarment and Suspension (2 CFR 2700)
The small business certifies, by submission of this form for program participation or contract award that neither it nor its
principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from
participation in this transaction by any Federal department or agency.
Where the small business is unable to certify to any of the statements in this certification, such participants shall attach an
explanation.

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