Form SBA Form 468.1 SBA Form 468.1 Annual Financial Report

ANNUAL FINANCIAL REPORT

OMB Approval No. 3245-0063
Expiration Date 10/31/2017

ON SBA FORM 468
(Corporate SBICs)

Name of Licensee:

Test SBIC annual

License Number:

12/34-5679

Street Address:
City, State, and Zip Code:

,,

County:

Employer ID Number:

33-3333333

For the Reporting Period
Ending:

12/31/2015

Months:

12

A - Fund Focus:

B - Ownership:

Bank Associated Corporation

Please Note: The estimated burden for completing this form is 35 hours per response if a wind-up plan is required and
25 hours per response if a wind-up plan is not required. You will not be required to respond to this information
collection if a valid OMB approval number is not displayed. The collection of this information is required so that
respondents can retain various benefits associated with an SBIC license, which may include access to SBA leverage on
favorable terms and various other tax and regulatory benefits. If you have questions or comments concerning this
estimate of hours per response 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.
All Form 468s must be prepared and submitted electronically using the SBIC-WEB Application provided by SBA.
PLEASE DO NOT SEND FORMS TO OMB.

SBA Form 468.1 (03/14) Previous edition obsolete.

1 of 21

Page 1C

STATEMENT OF FINANCIAL POSITION
AS OF 12/31/2015
(Amounts rounded to the nearest dollar)
Name of the Licensee:

Test SBIC annual

License Number: 12/34-5679

ASSETS:
LOANS AND INVESTMENTS

OMB Approval No. 3245-0063
Expiration Date 10/31/2017

Unrealized
Depreciation
(Col. 2)

Cost:
(Col. 1)

Unrealized
Appreciation
(Col. 3)

Reported
Value (1)
(Col. 4)

Portfolio Securities:
1 Loans

$0

$0

$0

$0

2 Debt Securities

$0

$0

$0

$0

3 Equity Securities

$0

$0

$0

$0

4 Total Portfolio Securities

$0

$0

$0

$0

5 Receivables from Sale of Assets Acquired

$0

$0

$0

$0

6 Assets Acquired

$0

$0

$0

$0

7 Total Assets Acquired

$0

$0

$0

$0

8 Operating Concerns Acquired

$0

$0

$0

$0

9 Notes and Other Securities Received

$0

$0

$0

$0

10 TOTAL LOANS AND INVESTMENTS

$0

$0

$0

$0

Assets Acquired in Liquidation of Portfolio Securities:

11 Less Current Maturities

$0

12 Loans and Investments Net of Current Maturities

$0

Investment in 301(d) Licensee (2)
13 Name/License No.

$0

CURRENT ASSETS
14 Cash and Cash Equivalents

$0

15 Invested Idle Funds

$0

16 Interest and Dividends Receivable

$0

17 Notes and Accounts Receivable

$0

18 Receivables from Parent or Other Associates

$0

19 Less: Allowance for Losses (lines 16, 17, and 18)

$0

20 Current Maturities of Portfolio Securities

$0

21 Current Maturities of Assets Acquired

$0

22 Current Maturities of Operating Concerns Acquired

$0

23 Current Maturities of Other Securities

$0

$0

$0

$0

24 Other (specify)

$0

25 Other (specify)

$0

$0

OTHER ASSET
26 Net Furniture and Equipment

$0

27 Net Leverage Fees

$0

28 Other (specify)

$0

29 Other (specify)

$0

30 TOTAL ASSETS

$0
$0

(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 468.1 (03/14) Previous edition obsolete.

Page 2C

2 of 21

STATEMENT OF FINANCIAL POSITION
AS OF 12/31/2015
(Amounts rounded to the nearest dollar)
Name of the Licensee:

OMB Approval No. 3245-0063
Expiration Date 10/31/2017

License No: 12/34-5679

Test SBIC annual

LIABILITIES AND CAPITAL
Liabilities
Long-Term Debt
31 Notes and Debentures payable to or guaranteed by SBA.

$0

32 Notes and Debentures Payable to Others

$0

33a. 4% Redeemable Preferred Stock (301(d) Licenses Only)

$0

b. Cumulative Undeclared 4% Dividends

$0

$0

$0

Current Liabilities
34 Accounts Payable

$0

35 Due to Parent or Other Associates
a. Management Expenses Due to Associates

$0

b. Other Due to Associates

$0

$0

36. Accrued Interest Payable

$0

37. Accrued Taxes Payable

$0

38. Dividends Payable

$0

39. Short-term notes Payable/Lines of Credit

$0

40 Other (specify)

$0

41 Other (specify)

$0

$0

Other Liabilities
42 Deferred Credits

$0

43 Deferred Fee Income

$0

44 Other (specify)

$0
$0

45 Total Liabilities

CAPITAL
46 Capital Stock

$0

ϰϳWĂŝĚͲŝŶ^ƵƌƉůƵƐ

$0

48 Restricted Contributed Capital Surplus

$0

49 Capital Stock and Surplus

$0

50 3% Preferred Stock Purchased by SBA

$0

51 Unrealized Gains (Loss) on Securities Held

$0

ϱϮEŽŶͲĂƐŚ'ĂŝŶƐͬ/ŶĐŽŵĞ

$0

53 Undistributed Net Realized Earnings
a. Restricted (Equal to Cost of Treasury Stock)

$0

b. Unrestricted

$0

c. Total (53a plus 53b)

$0

54 Undistributed Realized Earnings (line 52 plus line 53c)

$0

55 Total

$0

56: Less: Cost of Treasury Stock

$0

57 TOTAL CAPITAL

$0

58 TOTAL LIABILITIES AND CAPITAL (LINES 45 AND 57)

$0

SBA Form 468.1 (03/14) Previous edition obsolete.

Page 3C

3 of 21

STATEMENT OF OPERATIONS REALIZED
For 12 MONTHS ENDED 12/31/2015
(Amounts rounded to the nearest dollar)
Name of the Licensee:

OMB Approval No. 3245-0063
Expiration Date 10/31/2017

Test SBIC annual

License No: 12/34-5679

INVESTMENT INCOME
1 Interest Income

$0

2 Dividend Income

$0

3 Income (Loss) from Investments in Partnerships/Flow-through Entities

$0

4 Income (Loss) from Investments in Section 301(d) Licensee

$0

5 Fees for Management Services

$0

6 Application, Closing and Other Fees

$0

7 Interest on Cash Equivalents and Invested Idle Funds

$0

8 Income from Assets Acquired in Liquidation of
Loans and Investment (net of $0 Expenses)

$0

9 Other Income

$0
$0

10 GROSS INVESTMENT INCOME
EXPENSES
11 Interest Expense
a. Interest Expense -- SBA Debentures

$0

b. Other Interest Expense

$0

$0

12 Commitment Fees & Other Financial Costs

$0

13 Compensation and Benefits (Officer and Employee)

$0

14 Investment Advisory and Management Services

$0

15 Director's and Stockholder's Meetings

$0

16 Appraisal and Investigation

$0

17 Advertising, Communication and Travel

$0

18 Cost of Space Occupied

$0

19 Depreciation and Amortization
a. Amortization of Leverage Fees

$0

b. Other Depreciation and Amortization

$0

$0

20 Insurance

$0

21 Payroll and Other Taxes

$0

22 Provision for Losses on Receivables (excluding loans receivable)

$0

23 Legal Fees

$0

24 Audit and Examination Fees

$0

25 Miscellaneous Expenses
a. Misc. #1

$0

b. Misc. #2

$0

c. Misc. #3

$0

d. Misc. #4

$0

e. Misc. #5

$0

f. Misc. #6

$0

$0

26 TOTAL EXPENSES

$0

27 NET INVESTMENT INCOME (LOSS) BEFORE INCOME TAXES

$0

28 NET REALIZED GAIN (LOSS) ON INVESTMENTS BEFORE INCOME TAXES (1)

$0

29 NET INCOME (LOSS) BEFORE INCOME TAXES AND NONRECURRING ITEMS

$0

30 Income Tax Expense (Benefit)

$0

31 NET INCOME (LOSS) BEFORE NONRECURRING ITEMS

$0

32 Extraordinary Item

$0

33 Cumulative Effect of Change in Accounting Principle

$0

34 NET INCOME (LOSS)

$0

(1) Provide supporting detail for all realized gains and losses on Page 13P of this form.

SBA Form 468.1 (03/14) Previous edition obsolete.

4 of 21

Page 4C

STATEMENT OF CASH FLOWS
For 12 MONTHS ENDED 12/31/2015
(page 1 of 2)
(Amounts rounded to the nearest dollar)
Name of the Licensee:

OMB Approval No. 3245-0063
Expiration Date 10/31/2017

License No: 12/34-5679

Test SBIC annual

OPERATING ACTIVITIES
Cash Inflows
1 Interest Received from Portfolio Concerns

$0

2 Dividend Received from Portfolio Concerns

$0

3 Other Income Received from Portfolio Concerns

$0

4 Management Services and Other Fees Received

$0

5 Interest on Cash Equivalents and Invested Idle Funds

$0

6 Cash Received from Assets Acquired in Liquidation

$0

7 Other Operating Cash Receipts

$0

Cash Outflows
8 Interest Paid

$0

9 Commitment Fees and Other Financial Costs

$0

10 Investment Advisory and Management Fees

$0

11 Officers, Directors and Employees' Compensation and Benefits

$0

12 Operating Expenditures (Excluding Compensation and Benefits)

$0

13 Income Taxes paid

$0

14 Other Operating Cash Disbursements

$0
$0

15 NET CASH PROVIDED BY (USED IN) OPERATING ACTIVITIES
INVESTING ACTIVITIES
Cash Inflows
16 Loan Principal Payments Received from Portfolio Concerns

$0

17 Returns of Capital Received from Portfolio Concerns

$0

18 Net Proceeds from Disposition of Portfolio Securities

$0

19 Liquidation of Idle Funds Investments

$0

20 Other (Specify)

$0

Cash Outflows
21 Purchase of Portfolio Securities

$0

22 Loans to Portfolio concerns

$0

23 Idle Funds Investment

$0

24 Other (Specify)

$0

25 NET CASH PROVIDED BY (USED IN) INVESTING ACTIVITIES

$0

FINANCING ACTIVITIES
Cash Inflows
26 Proceeds from Issuance of SBA-Guaranteed Debentures

$0

27 Proceeds from Non-SBA Borrowing

$0

28 Proceeds from Sale of Stock or Other Capital Contribution

$0

29 Other (Specify)

$0

Cash Outflows
30 SBA Leverage Fees

$0

31 Principal Payments on SBA-Guaranteed Debentures

$0

32 Principal Payments on Non-SBA Borrowing

$0

33 Redemption of 4% Preferred Stock

$0

34 Redemption of 3% Preferred Stock

$0

35 Redemption of Stock (excluding 3% and 4% Preferred)

$0

36 Dividends Paid

$0

37 Other (Specify)

$0

38 NET CASH PROVIDED BY (USED IN) FINANCING ACTIVITIES

SBA Form 468.1 (03/14) Previous edition obsolete.

$0

5 of 21

Page 5C

STATEMENT OF CASHFLOW
12 MONTHS ENDED 12/31/2015
(page 2 of 2)
(Amounts rounded to the nearest dollar)
Name of the Licensee:

OMB Approval No. 3245-0063
Expiration Date 10/31/2017

License No: 12/34-5679

Test SBIC annual

39 INCREASE (DECREASE) IN CASH AND CASH EQUIVALENTS

$0

40 CASH AND CASH EQUIVALENTS AT BEGINNING OF PERIOD

$0

41 CASH AND CASH EQUIVALENTS AT END OF PERIOD (line 14, page 2C)

$0

RECONCILIATION OF NET INCOME (LOSS) TO NET CASH PROVIDED BY (USED IN) OPERATING ACTIVITIES
42 Net Income (Loss) (Line 34, page 4C)

$0

Adjustments to Reconcile Net Income (Loss) to Net Cash Provided by (used in) Operating Activities:
43 Depreciation and Amortization (line 19, page 4C)

$0

44 Provision for Losses on Accounts Receivable (line 22, page 4C)

$0

45 Provision for Deferred Income Taxes

$0

46 Realized (Gains) Losses on Investments (line 28, page 4C)

$0

47 Other (Specify)
a.

$0

b.

$0

c.

$0

$0

Changes in Operating Assets and Liabilities Net of Noncash Items
48 (Increase) Decrease in Interest and Dividends Receivable

$0

49 (Increase) Decrease in Other Current Assets

$0

50 Increase (Decrease) in Accounts Payable

$0

51 Increase (Decrease) in Accrued Interest Payable

$0

52 Increase (Decrease) in Accrued Taxes Payable

$0

53 Increase (Decrease) in Dividends Payable

$0

54 Increase (Decrease) in Other Current Liabilities

$0

55 Other (Specify)

$0

56 Other (Specify)

$0

57 NET CASH PROVIDED BY (USED IN) OPERATING ACTIVITIES

$0

(Total must agree with line 15, page 5C)

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

SBA Form 468.1 (03/14) Previous edition obsolete.

Page 6C

6 of 21

STATEMENT OF STOCKHOLDER'S EQUITY
AS OF 12/31/2015
(Amounts rounded to the nearest dollar)
Name of the Licensee:

OMB Approval No. 3245-0063
Expiration Date 10/31/2017

Test SBIC annual

License No: 12/34-5679
Capital Stock
(page 3C, line
46)

WZd/͘W/d>^dK<EW/Ͳ/E^hZW>h^

1 BALANCE AT BEGINNING OF PERIOD
2 ADDITIONS:

W/Ͳ/E
SURPLUS

Total

$0

$0

$0

a. Capital stock issued for cash
b. Capital stock issued for services rendered

$0

$0

$0

$0

$0

$0

Đ͘ĂƉŝƚĂůƐƚŽĐŬŝƐƐƵĞĚĨŽƌĐŽŶƚƌŝďƵƚĞĚŶŽŶͲĐĂƐŚĂƐƐĞƚƐ

$0

$0

$0

d. Capitalization of Retained Earnings Available for Distribution

$0

$0

$0

e. Gain on Sale of Treasury Stock

$0

$0

$0

f. Other credits (specify)
3 Total additions (sum of 2a through 2f)

$0

$0

$0

$0

$0

$0

4 Subtotal (line 1 plus line 3)

$0

$0

$0

a. Retirement of capital stock

$0

$0

$0

b. Return of capital distributions

$0

$0

$0

c. Loss on sale of Treasury Stock

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

5 DEDUCTIONS:

d.Other debits (specify)
6 Total deductions (sum of 5a through 5b)
7 BALANCE AT END OF PERIOD (line 4 minus line 6) -Total must agree with lines 46 and 47, page 3C

PART II. UNDISTRIBUTED REALIZED EARNINGS

NONCASH
UNDISTRIBUTED UNDISTRIBUTED
GAINS / INCOME NET
REALIZED
(1)
REALIZED
EARNINGS (1) +
EARNINGS (2)
(2)

1 BALANCE AT BEGINNING OF PERIOD

$0

$0

$0

a. Net investment income

$0

$0

$0

b. Realized gain (loss) on investments

$0

$0

$0

c. Gain on appreciation of securities distributed in kind

$0

$0

$0

d. Other (specify)

$0

$0

$0

3 Total additions (sum of 2a through 2d)

$0

$0

$0

4 Subtotal (line 1 plus line 3)

$0

$0

$0

$0

$0

$0

$0

$0

$0

2 ADDITIONS:

5 DEDUCTIONS:
Ă͘ŝǀŝĚĞŶĚƐͲĂƐŚ
ď͘ŝǀŝĚĞŶĚƐͲ^ƚŽĐŬ
Đ͘ŝǀŝĚĞŶĚƐͲ/ŶͲ<ŝŶĚ;ĂƚĨĂŝƌǀĂůƵĞͿ

$0

d. Capitalization of Retained Earnings available for Distribution

$0

$0

$0

$0

$0

6 Total deductions (sum of 5a through 5e)

$0

$0

$0

7 Total before collection of non-cash gains/income
(line 4 minus line 6)

$0

$0

$0

8 Collection of non-cash gains/income

$0

$0

9 BALANCE AT END OF PERIOD (line 7 plus line 8) Totals must agree with lines 52, 53c and 54, page 3C

$0

$0

e. Other (specify)

SBA Form 468.1 (03/14) Previous edition obsolete.

$0

Page 7C
7 of 21

I.RETAINED EARNINGS AVAILABLE FOR DISTRIBUTION
II. REGULATORY AND LEVERAGEABLE CAPITAL
AS OF 12/31/2015
(Amounts rounded to nearest dollar)
Name of the Licensee:

OMB Approval No. 3245-0063
Expiration Date 10/31/2017

License No: 12/34-5679

Test SBIC annual

PART I. RETAINED EARNINGS AVAILABLE FOR DISTRIBUTION OR CAPITALIZATION.
1 Undistributed net Realized Earnings (line 53, page 3C)

$0

2 LESS: Unrealized Depreciation (line 10, column 2, page 2C)

$0

3 ADD: Cumulative Unpaid distributions on 4% Redeemable
WƌĞĨĞƌƌĞĚ^ƚŽĐŬͲͲ^ĞĐƚŝŽŶ301(d) Licensees only (line 33b, page 3C)

$0

4 RETAINED EARNINGS AVAILABLE FOR DISTRIBUTION OR CAPITALIZATION

$0

PART II. SCHEDULE OF REGULATORY AND LEVERAGEABLE CAPITAL
1 Capital Stock and Paid-in Surplus (sum of lines 46 and 47, page 3C)

$0

2 ADD:

$0

Unfunded binding commitments from Institutional Investors

3 LESS: Regulatory Distributions
a. Organization Expenses Not Approved by SBA (1)

$0

b. Capital Stock Issued for Services

$0

Đ͘ĂƉŝƚĂů^ƚŽĐŬ/ƐƐƵĞĚĨŽƌEŽŶͲĐĂƐŚƐƐĞƚƐ;ƵŶůĞƐƐĂƉƉƌŽǀĞĚďLJ
SBA for inclusion in Regulatory Capital or converted to cash)

$0

d. Treasury Stock at Cost

$0

e. Other (specify)

$0

4 Total Regulatory Deductions (Sum of 3a through 3d)

$0

5 Other Adjustments to Regulatory Capital (specify)

$0

6 REGULATORY CAPITAL (sum of lines 1, 2, 4, and 5)

$0

7 LESS: Unfunded binding commitments from Institutional Investors

$0

8 LESS: Non-cash assets included in Regulatory Capital, other than eligible investments in Small Concerns

$0

9 LESS: Other deductions (specify)

$0

10 LEVERAGEABLE CAPITAL (sum of lines 6 through 9)

$0

PART IIa. ADJUSTMENT TO REGULATORY CAPITAL FOR CAPITAL IMPAIRMENT AND OVERLINE PURPOSES
PART IIa ONLY APPLIES IF LICENSEE HAS COMPLETED THE REPURCHASE OF ITS 3% PREFERRED STOCK FROM
SBA.
11 REGULATORY CAPITAL (Part II, line 6)

$0

12 ADD: Restricted Contributed Capital Surplus (line 48, page 3C)

$0

13 ADJUSTED REGULATORY CAPITAL FOR CAPITAL IMPAIRMENT AND OVERLINE PURPOSES (line 11 plus line 12)

$0

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

SBA Form 468.1 (03/14) Previous edition obsolete.

Page 8C
8 of 21

SCHEDULE OF COMMITMENTS AS OF 12/31/2015

OMB Approval No. 3245-0063
Expiration Date 10/31/2017

Name of the Licensee:

License No: 12/34-5679

Test SBIC annual
1

2

3

4

5

6

7

Name of Small Business

Employer ID

Amount of
Commitment

Date Made

Expiration Date

Loan, Debt, or
Equity?

New investment or
follow-on?

Total

SBA Form 468.1 (03/14) Previous edition obsolete.

Page 9C
9 of 21

SCHEDULE OF GUARANTEES AS OF 12/31/2015

Name of the Licensee:

OMB Approval No. 3245-0063
Expiration Date 10/31/2017

License No: 12/34-5679

Test SBIC annual

1

2

3

Name of Small Business / Employer ID

Guarantee
Amount

Date
Made

4

5

6

7

Expiration Date

Name of Guaranteed
Party

Is guarantee
collateralized? If so, by
what?

Description of underlying
obligation of Small Business

/

Total

SBA Form 468.1 (03/14) Previous edition obsolete.

Page 10C
10 of 21

SCHEDULE 1

SCHEDULE OF LOANS AND INVESTMENTS AS OF
12/31/2015

Name of the Licensee:

OMB Approval No. 3245-0063
Expiration Date 10/31/2017

License No. 12/34-5679

Test SBIC annual

Portfolio Company Name

Employer ID

test

% Own

99-1234567

% Vote

0%

Cost at End of Period

0%

Unrealized App (Dep)
$0

Total Reported Value
$0

$0

Loans and Investments (ordered by date ascending)
Investment Date

Investment Type

Initial Invest.
Amount

1/1/2015 Equity
Other Notes:

$0

Qualifies as start-up per CFR 107.50?

Smaller Enterprise?

No

Cost at Beg. of
Period
$0

Additions /
Deductions

Description of Addition / Deductions

$0 01/01/2015 - Equity

No

$0

Total Reported
Value

$0

Equity Capital? No
Number of Shares:

Common Stock

Market /Liquidity:

Equity Features: 0

$0

Class II Appreciation Amount

$0

Loan/Debt Information:
Maturity Date:

Status:
Interest Rate:

Repay. Terms:
Collateral :

No

Expiration Date:

$0

Class I Appreciation Amount:
If Class II, Date of Up Round?

Equity Information:

Warrants?

Unrealized App
(Dep)

Class I and II Appreciation:

Comments:
Type of Shares:

Cost At End of
Period

Date Investment Concluded:

SBA Form 468.1 (03/14) Previous edition obsolete.

11 of 21

Page 11C

SCHEDULE 1 A/B

1 A. SUMMARY OF LOANS AND INVESTMENTS 1 B.
SMALLER ENTERPRISE FINANCINGS AS OF
12/31/2015

Name of the Licensee:

OMB Approval No. 3245-0063
Expiration Date 10/31/2017

License No: 12/34-5679

Test SBIC annual

1 A. SUMMARY OF LOANS AND INVESTMENTS
1

Investment Category

2

3

Cost at Beginning
of Period

Additions/
(Deductions)

4

5

6

Cost at End of
Period

Unrealized
Appreciation
(Depreciation)

Reported Value

Total Loans (line1, page 2C)

$0

$0

$0

$0

$0

Total Debt Securities (line 2, page 2C)

$0

$0

$0

$0

$0

Total Equity Securities (line 3, page 2C)

$0

$0

$0

$0

$0

Total Portfolio Securities (line 4, page 2C)

$0

$0

$0

$0

$0

Total Assets Acquired (line 7, page 2C)

$0

$0

$0

$0

$0

Total Operating Concerns Acquired (line 8, page 2C)

$0

$0

$0

$0

$0

Total Notes and Other Secs. Received (line 9, page 2C)

$0

$0

$0

$0

$0

Total Loans and Investments (line 10, page 2C)

$0

$0

$0

$0

$0

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

$0

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

$0

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

0.00%

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

SBA Form 468.1 (03/14) Previous edition obsolete.

Page 12C
12 of 21

Schedule 2

SCHEDULE OF REALIZED GAINS AND LOSSES ON
LOANS AND INVESTMENTS FOR 12 MONTHS ENDED
12/31/2015

OMB Approval No. 3245-0063
Expiration Date 10/31/2017

Name of the Licensee: Test SBIC annual
1

License No: 12/34-5679

2

3

4

5

6

7

8

9

10

Equity / Type

Name and Address of
Purchaser (applies to
sales and exchanges)

Components of Net Sales Price

Name of Small Business /
Employer ID

Security
Type (1)

Transaction
Type (2) /
Date

Net Sales
Price

Cost

Realized
Gains / (Loss)

Note/
Maturity
Date

Cash
/

/

/
Escrow Exp. Comments :

Total

(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 468.1 (03/14) Previous edition obsolete.

Page 13C
13 of 21

Schedule 3

SCHEDULE OF NONCASH GAINS/INCOME as of
12/31/2015

Name of the Licensee:

License No: 12/34-5679

Test SBIC annual

1
Name of Small Business /
Employer ID

OMB Approval No. 3245-0063
Expiration Date 10/31/2017

2

3

Description of Non-cash
Gains / Income (1)

Balance at
Beginning of
Period

4

Additions

5
Collections
During Period

6

7

Balance at End of Amount of "Includible Non-cash
Period
Gains" for Capital Impairment

/

Total

(1) Examples of non-cash gains and income include the following:
- Non-cash gains on sale or exchange of securities
- Interest income accrued on deferred interest notes, zero coupon bonds or similar instruments
- Dividends received in kind
- Accrued interest converted into a new note or added to principal of an existing note. The amount of any such interest which was previously included in Undistributed Net Realized
Earnings must be reclassified to Non-cash Gains/Income.

SBA Form 468.1 (03/14) Previous edition obsolete.

Page 14C
14 of 21

Schedule 4

SCHEDULE OF DELINQUENT LOANS AND
INVESTMENTS AS OF 12/31/2015

Name of the Licensee:

Expiration Date 10/31/2017

License No: 12/34-5679

Test SBIC annual

1

2

3

4

Delinquent Principal:
Name of Small Business /
Employer ID

OMB Approval No. 3245-0063

Outstanding
Amount Past
Principal Balance
Due

Days Past
Due (1)

5

6

Delinquent Interest
Amount
Past
Due

Days Past
Due (1)

7

8

Date of Last Payment

Principal

Interest

9

10

11

Amount of Last Payment

Principal

Interest

Fair Market Value of
Collateral

Total

(1) Based on oldest delinquency.

SBA Form 468.1 (03/14) Previous edition obsolete.

Page 15C
15 of 21

Schedule 5

SCHEDULE OF CASH AND INVESTED IDLE FUNDS
AS OF 12/31/2015

Name of the Licensee:

OMB Approval No. 3245-0063
Expiration Date 10/31/2017

License No: 12/34-5679

Test SBIC annual

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

Maturity Date

Amount

II. REPURCHASE AGREEMENTS WITH FEDERALLY-INSURED INSTITUTION

Name and Location of Financial Institution

III. CERTIFICATES OF DEPOSIT ISSUED BY FEDERALLY-INSURED INSTITUTIONS

Name and Location of Financial Institution

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 2C)

SBA Form 468.1 (03/14) Previous edition obsolete.

Page 16C
16 of 21

Schedule 6

Name of the Licensee:

SCHEDULE OF ACTIVITY AS OF 12/31/2015

OMB Approval No. 3245-0063
Expiration Date 10/31/2017

License No: 12/34-5679

Test SBIC annual

PART I. FIRST ACTIVITY TEST
1. Cash and Cash Equivalents (line 14, page 2C)

$0

2. Invested Idle Funds (line 15, line 2C)

$0

3. Total Cash and Idle Funds

$0

4. Total Assets at Cost:
a. Total Assets (line 30, page 2C)

$0

b. ADD: Unrealized Depreciation (line 10, col. 2, page 2C)

$0

c. LESS: Unrealized Appreciation (line 10, col 3, page 2C)

$0

d. Total Assets at Cost

$0

5. Line 3 Divided by Line 4d (expressed as a percentage)

0%

IF LINE 5 IS LESS THAN OR EQUAL TO 20%, LICENSEE IS NOT INACTIVE -- DO NOT COMPLETE PART II
IF LINE 5 IS GREATER THAN 20%, COMPLETE THE SECOND ACTIVITY TEST IN PART II

PART II. SECOND ACTIVITY TEST

6. Financings during the Past 18 Months:
a. Loans

$0

b. Debt

$0

c. Equity

$0

d. Guarantees

$0

7. Total (lines 6a through 6d)

$0

8. Regulatory Capital

$0

9. Line 7 divided by Line 8 (expressed as a percentage)

0%

IF LINE 9 IS LESS THAN 20%, LICENSEE MAY BE INACTIVE UNDER SECTION 107.590 ATTACH EXPLANATION OF INACTIVITY AND PLANNED CORRECTIVE ACTION.

SBA Form 468.1 (03/14) Previous edition obsolete.

Page 17C
17 of 21

Schedule 7

SHAREHOLDERS, OFFICERS, DIRECTORS AND
MANAGEMENT
AS OF 12/31/2015

Name of the Licensee:

1

OMB Approval No. 3245-0063
Expiration Date 10/31/2017

License No: 12/34-5679

Test SBIC annual

2

3

4

5

6
Percent Owned or Controlled of Total
Class

Name and Address

Officer /
Director/
Manager -- give
exact titles

Title of class
Owned or
Controlled

Shares legally
owned, beneficially
owned, or
controlled?

Number of
shares

Beginning of
Period

End of Period

/
%

SBA Form 468.1 (03/14) Previous edition obsolete.

%

Page 18C
18 of 21

OPERATING PLAN UPDATE

Name of the Licensee:

OMB Approval No. 3245-0063
Expiration Date 10/31/2017

License No: 12/34-5679

Test SBIC annual

INSTRUCTIONS
Any Licensee, which has SBA leverage outstanding or which expects to apply for leverage in the current fiscal year, must prepare an annual
update of its plan of operations. The update must be submitted to SBA as an addenum to the Licensee's Annual Financial Report on Form 468.
SBA will consider the information provided as part of its evaluation of the financial soundness of the Licensee, in accordance with the
provisions of Section 406 of the Small Business Equity Enhancement Act.
The plan update must include analysis and discussion of key events of the past year, as well as expectations for the current year. SBA expects
that most Licensees will be able to provide the required information in a narrative of no more than 3 pages.
Content of the Report
1. For the fiscal year ended, the Licensee should discuss the following:
a. Major positive and negative events which affected overall performance during the year, including exits / distributions / write- offs of
investments; highlight any significant differences between last year's plan and actual performance.
b. Any significant changes in the operations of the Licensee, such as changes in organizational structure, scope of operations, level or phase of
investment activity, or types of investments being made.
c. Any management changes.
d. Any lawsuits or other events giving rise to contingent liabilities.
2. For the current fiscal year, the Licensee should discuss the following:
a. Levels of new and follow-on investment anticipated
b. Anticipated exits/distributions/write-offs from investments
c. Any material changes expected in investment strategy or portfolio composition
d. Any material changes expected in overhead expenditures
e. Any changes expected in management
f. Any other anticipated events which may have a significant effect on Licensee's performance.
3. If an SBIC is in Liquidation, wind-up or has been otherwise requested to provide a wind-up plan, the SBIC shall provide a wind-up plan as
part of the Operating Plan Update. Per 13 CFR 107.590, SBICs in Operations must submit wind-up plans for SBA approval. After SBICs receive
approval, they should provide updated windup plans on an annual basis as part of this Operating Plan Update. (See attached supplement.)

SBA Form 468.1 (03/14) Previous edition obsolete.

Page 19C
19 of 21

SCHEDULE 8

Name of the Licensee:

OMB Approval No. 3245-0063

Unaudited Portfolio Company Information
AS OF 12/31/2015

Expiration Date 10/31/2017

Test SBIC annual

License No. 12/34-5679

Portfolio Company Name

Employer ID

% Own

% Vote

Cost at End of Period

Unrealized App (Dep)

Total Reported Value

test

99-1234567

0%

0%

$0

$0

$0

General Portfolio Company Information
Business Description:

Fiscal Year End:

NAICS: 111110

Overline? No

Current Stage: Seed
Exchange:

Stock Symbol:

If original investment company's name changed, was acquired/merged,
company name of original investment:
Address: 111 test Dr
City/State: Test City / Alabama
Zip Code: 12345
Other Comments:

Period 1

Period 2

Period 3

As Of Date

Soybean farming, field and seed production

1st Date Invested:

Portfolio Company Financial Information

Rounded to nearest $

LMI: No

Basis Period
Revenues

$0

$0

$0

Gross Profit

$0

$0

$0

EBITDA

$0

$0

$0

Interest Charges

$0

$0

$0

Net Income

$0

$0

$0

Cashflow from Ops.

$0

$0

$0

Burn Rate

$0

$0

$0

Cash Balance

$0

$0

$0

Current Assets

$0

$0

$0

Fixed Assets

$0

$0

$0

Total Assets

$0

$0

$0

Current Liabilities

$0

$0

$0

Debt

$0

$0

$0

Total Liabilities

$0

$0

$0

EOY Equity Value (Market)

$0

$0

$0

EOY Enterprise Value

$0

$0

$0

Full-time employees : Federal Taxes Paid : $0

SBA Form 468.1 (03/14) Previous edition obsolete.

20 of 21

State Taxes Paid : $0

Page 20C

CERTIFICATIONS

OMB Approval No. 3245-0063
Expiration Date 10/31/2017

Name of Licensee: Test SBIC annual

License No.: 12/34-5679

MANAGEMENT CERTIFICATION
I, the Chief Financial Officer of Test SBIC annual (License), do hereby certify as follows:

1. The audited Annual Financial Report for the fiscal year ended 12/31/2015 submitted by Test SBIC annual (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.
STATEMENTS AND SCHEDULES OMITTED:

$0
$0
$0

Total Assets:
Net Income(Loss):
Cash and Cash Equivalents at End of Period:

CAUTION: By signing below, you are certifying as to the truth and accuracy of theFinancial 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.

Date: 06/09/2016

Name:

Signature:

Title:

Title:
Date:

SECRETARY'S CERTIFICATION
I, the duly elected, qualified and acting Secretary of Test SBIC annual (License), do hereby certify as follows:
1. Test SBIC annual (Licensee) is in good standing under the laws of the State of .
2. The minutes of the meeting of the Board of Directors of Test SBIC annual (Licensee) on , document that the Board at such
meeting, reviewed and approved the audited Annual Financial Report of such company for the fiscal year ended 2015.

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.

Date: 06/09/2016

Name:

Signature:

Title:

Title:
Date:

SBA Form 468.1 (03/14) Previous edition obsolete.

Page 21C
21 of 21