SBA Form 480 SIZE STATUS DECLARATION

U.S. SMALL BUSINESS ADMINISTRATION
SIZE STATUS DECLARATION

OMB Approval No. 3245-0009
Expiration Date 01/31/2017

Use of Information. The information requested below will be used by SBA to determine the Applicant’s (“Applicant”)
eligibility to receive financing or consulting and advisory services from a small business investment company licensed
by SBA (“Licensee”).
Instructions for submitting completed form. The Applicant should complete Part A and Part B (if necessary), sign the
Applicant’s certification, and return the form to the Licensee from whom it is seeking assistance. The Licensee
should sign the Licensee’s certification and retain the form in its files. SBA may request the completed form during
an on-site examination of the Licensee.

Name and address of Licensee

Name and address of Applicant

Applicant’s Form of Organization: ___Corporation ___Partnership ___Limited Liability Company
___Proprietorship
PART A
1.

Does the Applicant business have any Affiliates? If yes, attach a list to this form.

Yes
___

No
___

2.

Does Applicant (including affiliates) have tangible net worth in excess of $18,000,000?
(Tangible net worth = total net worth minus goodwill)

___

___

3.

Does Applicant (including affiliates) have average net income after Federal income
taxes (excluding any carry-over losses) for the preceding 2 completed fiscal years in
excess of $6,000,000?

___

___

Affiliation exists when one individual or entity controls or has the power to control another or a third
party or parties controls or has the power to control both. SBA considers factors such as ownership,
management, previous relationships with or ties to another entity, and contractual relationships when
determining whether affiliation exists. The complete definition of affiliation is found at 13 CFR
121.103. (See also, 13 CFR 121.107 and 121.301.) Examples of Affiliates include: (1) a parent
company; (2) subsidiaries and other companies that are owned or controlled by the Applicant; (4)
companies under common management with the Applicant; and (5) companies that have entered into
agreements to merge with the Applicant. Additional guidance on affiliation can be found on SBA’s size
standards website at http://www.sba.gov/size under "Guide to Size Standards”.

PART B
Applicant must complete this part only if the answer to either question in Part A was “Yes”. Applicant must
not exceed the size standard for (1) the industry in which the Applicant combined with its affiliates is
primarily engaged, and (2) the industry in which the Applicant alone is primarily engaged. Find the
appropriate industry size standard under the NAICS code for your primary industry in 13 CFR 121.201.
1. Primary industry (include NAICS code):
Applicant combined with affiliates__________________

Applicant alone__________________

2. Total annual receipts of Applicant (excluding affiliates) for each of its 3 most recently completed fiscal
years (see 13 CFR 121.104):
Year ended ______________
$___________________
Year ended ______________
$___________________
Year ended ______________
$___________________
SBA Form 480 (1-14) Previous Editions Obsolete

1

3. Applicant’s average number of employees (excluding affiliates) based on the number of persons
employed on a full-time, part-time, temporary, or other basis during each of the pay periods of the
preceding 12 calendar months (see 13 CFR 121.106): ________________________
4. Affiliates of Applicant (domestic and foreign) Total annual receipts of affiliates
(excluding Applicant) for past 3
Names and full addresses
completed fiscal years

a.

b.

c.

SBA Form 480 (1-14) Previous Editions Obsolete

Yr.___________
Yr.___________
Yr.___________
3-year average

$____________
$____________
$____________
$____________

Yr.___________
Yr.___________
Yr.___________
3-year average

$____________
$____________
$____________
$____________

Yr.___________
Yr.___________
Yr.___________
3-year average

$____________
$____________
$____________
$____________

Average no. of
persons employed
by affiliates
(excluding
Applicant) on fulltime, part-time,
temporary or other
basis during each
of the pay periods
of the preceding 12
calendar months

111111111111111111
111111111111111111
111111111111111111
111111111111111111
111111111111111111
1
111111111111111111
1
111111111111111111
111111111111111111
111111111111111111
111111

2

Applicant’s Certification
Applicant, through its duly authorized officer, hereby certifies that all information herein and in attachments
hereto is true and complete to the best of its knowledge and belief. Applicant further certifies that it intends
to conduct, for a period of not less than 1 year from the date of the final disbursement of the funds involved
in the subject financing and for a period of not less than 1 year from the date of the commencement of the
consulting or advisory services, as a regular and continuous business operation, the business operation for
which the application for financing or consulting or advisory services is being made.
WARNING By signing below, you are acknowledging that the U.S. Small Business Administration (SBA) is 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 Applicant:
Date:

By: (Signature of Officer)

Title:

Licensee’s Certification
Based upon all the information available to us, including all information and facts obtained through our own
investigation, the Licensee has concluded that the Applicant is a small business concern within the
requirements of the Small Business Investment Act of 1958, as amended, and the Regulations of SBA
thereunder.
WARNING By signing below, you are acknowledging that the U.S. Small Business Administration (SBA) is 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.

Licensee Name:
Date:

By: (Signature of Authorized Official)

Title:

PLEASE NOTE: The estimated burden for completing this form is 10 minutes. 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.
rd
Small Business Administration, Chief, AIB, 409 3 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 3245-0009).
PLEASE SUBMIT OR RETAIN THE COMPLETED FORM ACCORDING TO THE INSTRUCTIONS ABOVE. PLEASE DO NOT
SEND FORMS TO OMB.

SBA Form 480 (1-14) Previous Editions Obsolete

3