SBA Form 413 (8a) Personal Financial Statement

OMB APPROVAL NO.: 3245-0188
EXPIRATION DATE: 01/31/2018
PERSONAL FINANCIAL STATEMENT
8(a) Business Development Program
As of ________________ , ________

U.S. SMALL BUSINESS ADMINISTRATION

For the 8(a) Business Development (BD) Program, this information is necessary for SBA to determine if the
applicant or participant meets the economic disadvantaged and financial eligibility requirements to participate
in the program. Therefore, each individual claiming economic disadvantage must submit personal financial
information.
If married, an individual claiming economic disadvantage must submit separate financial information for his or
her spouse, unless the individual and the spouse are legally separated. You must complete this form and
submit it with your application through certify.sba.gov.
Additionally, any proprietor; partner; member of a limited liability company (LLC); or owner of 10% or more of
the equity of the business MUST complete this form.
Note: Please complete this form with Personal Information not Business information.

Name

Business Phone

Home Address

Home Phone

City, State, & Zip Code
Business Name of Applicant/Borrower
ASSETS

(Omit Cents)

LIABILITIES

(Omit Cents)

Cash on Hand & in banks…………………………$ ________________
Savings Accounts…………………………………..$ ________________
IRA or Other Retirement Account………………...$ ________________
(Describe in Section 4)
Roth……………… (Describe in Section 4)……..$ ________________
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……………………………$ ________________
i.e. Such as boat, jewelry, etc. (Describe in Section 5)
Other Assets………………………………………….$ _______________
(Describe in Section 5)
Mutual Funds (Describe in Section 3)
Applicant’s Business Equity……………………….$_________________
Equity in other firms…………………………………$________________
Total Assets
$ ________________
0

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)
0
Total Liabilities………………………………....$ _____________
0
Net Worth……………………………………….$ _____________

Section 1.

Contingent Liabilities

Source of Income.

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

Total Liabilities & Net Worth $ _____________
0
*Must equal total in assets column.

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

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

SBA Form 413 (8a) (09-14) Previous Editions Obsolete

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Description of Other Income in Section 1.

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, Bonds and Mutual Funds. (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-Primary Residence

Property B

Property C

Type of Real Estate (e.g.
Primary Residence, Other
Residence, Rental Property,
Land, etc.) (if jointly owned,
please explain)
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

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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.)

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

I authorize the SBA to make inquiries as necessary to verify the accuracy of the statements. CERTIFICATION: (to be completed by
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 an application for participation in the SBA 8(a) Business Development (BD) Program.
Signature ________________________________________

Date

____________________

Print Name _______________________________________

Social Security No.

____________________

Signature ________________________________________

Date

____________________

Print Name _______________________________________

Social Security No.

____________________

NOTICE TO APPLICANTS OR PARTICIPANTS IN THE 8(a) BD PROGRAM: CRIMINAL PENALTIES AND ADMINISTRATIVE
REMEDIES FOR FALSE STATEMENTS
Any person who misrepresents a business concern’s status as an 8(a) BD Program participant or SDB concern, or makes any other
false statement in order to influence the 8(a) certification or other review process in any way(e.g., annual review, eligibility review),
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 treble damages and civil
penalties under the False Claims Act, 31 U.S..C 3729; (4) subject to administrative remedies, including suspension and debarment;
and (5) ineligible for participation in programs conducted under the authority of the Small Business Act.

PLEASE NOTE:

According to the Paperwork Reduction Act, you are not required to respond to this request for information unless it displays a valid OMB
Control Number. The estimated average burden hours for the completion of this form is 1.5 hour per response. If you have questions or
comments concerning this estimate or any other aspect of this information collection, please contact: Director, Records Management
Division, Small Business Administration, 409 Third Street SW, Washington, D.C. 20416, and SBA Desk Officer, Office of Management and
Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503. PLEASE DO NOT SEND COMPLETED 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)
Any person can request to see or get copies of any personal information that SBA has in his or her file when that file is
retrieved by individual identifiers such as name or social security numbers. Requests for information about another party
may be denied unless SBA has the written permission of the individual to release the information to the requestor or
unless the information is subject to disclosure under the Freedom of Information Act.
Under the provisions of the Privacy Act, you are not required to provide your social security number. Failure to provide
your social security number may not affect any right, benefit or privilege to which you are entitled. Disclosures of name
and other personal identifiers are, however, required for a benefit, as SBA requires an individual seeking assistance from
SBA to provide it with sufficient information for it to make a character determination. In determining whether an
individual is of good character, SBA considers the person’s integrity, candor, and disposition toward criminal actions.
For all forms of assistance SBA is authorized to make all investigations necessary to ensure that a person has not engaged
in acts that violate or will violate the Act or the Small Business Investment Act, 15 USC Sections 634(b)(11) and 687(b)
(a), respectively. For these purposes, you are asked to voluntarily provide your social security number to assist SBA in
making a character determination and to distinguish you from other individuals with the same or similar name or other
personal identifier.
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 maintained in agency files and records to persons requesting it. Proprietary data, financial forms, confidential
business information and personally identifiable information are exceptions and will be protected to the extent the law
permits.
Executive Order 12549, Debarment and Suspension (13 C.F.R. 145)
The prospective lower tier participant certifies, by submission of the application for program participation (or
participant’s annual update) 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 prospective lower tier participant ( or active participant ) is unable to certify to any of the statements in this
certification, such participants shall attach an explanation.

SBA Form 413 (8a) (09-14) Previous Editions Obsolete

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