SBA Form 1941 A FINANCING ELIGIBILITY STATEMENT - "SOCIAL DISADVANTAGE"

OMB Control No. 3245-0301
Expiration Date XX/XX/XXXX

FINANCING ELIGIBILITY STATEMENT - "SOCIAL DISADVANTAGE"
(FOR INDIVIDUALS WHO ARE MEMBERS OF A DESIGNATED GROUP)
This form is to be completed by individuals who are claiming eligibility for SSBIC financing based on their
membership in one of the designated groups described below and in 13 CFR 124.103.

Individual's Name__________________________________________________

Applicant Business Name____________________________________________
Use of Information. The information requested below will be used by SBA to determine the Applicant’s
(“Applicant”) eligibility to receive financing from a small business investment company licensed by SBA
(“Licensee”) under Section 301(d) of the Small Business Investment Act. Under this provision, the Applicant
must meet the criteria stipulated in Appendix 1 of this form to be eligible to receive financing.
Instructions for submitting completed form. The Applicant must provide complete responses to each
question. If your answers require additional space, use plain white paper and properly identify 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. Once complete, sign the Applicant’s Certification of
Eligibility, and return the form to the Licensee from whom the Applicant is seeking financial 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. 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)

SBA Form 1941A (4-95)

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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 Licensee (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?

SBA Form 1941A (4-95)

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III.

APPLICANT’S CERTIFICATION OF ELIGIBILITY

Applicant, through its duly authorized officer, hereby certifies that all information herein and in attachments
hereto 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, 1031, 3571, and other statutes, with fines in excess of $1,000,000 and
imprisonment of up to 30 years, and civil fraud damages of three times the Government’s loss.

_________________________________________
Name of Applicant

_________________________________________
Typed Name and Title of Authorized Officer

_________________________________________
Signature of Authorized Officer

SBA Form 1941A (4-95)

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IV.

LICENSEE’S 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, 1031, 3571, and other statutes, with fines in excess of $1,000,000 and
imprisonment of up to 30 years, and civil fraud damages of three times the Government’s loss.

_________________________________________
Licensee Name

_________________________________________
Typed Name of Authorized Officer

_________________________________________
Signature of Authorized Officer

PLEASE NOTE: The estimated burden for completing this form is 1,5 hours. You are not required to respond to this or any
collection of information if a valid OMB control number is not displayed. If you have any questions or comments concerning this
estimate or other aspects of this information collection, please contact the U.S. Small Business Administration, Director, Records
Management Division, 409 3rd 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 Control Number 32450301). PLEASE SUBMIT OR RETAIN THE COMPLETED FORM ACCORDING TO THE INSTRUCTIONS ABOVE. PLEASE
DO NOT SEND FORMS TO OMB.

SBA Form 1941A (4-95)

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)