Form SBA Form 856 SBA Form 856 Disclosure Statement Leveraged Licensees

OMB CONTROL NO. 3245-0118
EXPIRATION DATE XX/XX/XX

U.S. SMALL BUSINESS ADMINISTRATION (SBA)
DISCLOSURE STATEMENT
LEVERAGED LICENSEES
____________________________________________________________________________________
The information collected below obtains representations from the management of a Small Business Investment
Company (SBIC) regarding certain obligations, transactions and relationships as part of an onsite examination of the
SBIC. Please return completed forms as directed by the requesting SBA Examiner.

____________________________________________________________________________________
TO: SBA EXAMINER
In connection with your examination of _______________________________________, as of
_______________________, I represent that to the best of my knowledge that all of the following
information is accurate: (Write “None” where applicable and expand rows where necessary.)
____________________________________________________________________________________
1.
All known liabilities of this licensee were recorded on the books of account except for the
following:

____________________________________________________________________________________
2.
No litigation was in progress or pending, or is now in progress or pending, except for the
following:

____________________________________________________________________________________
3.
The licensee has not provided financings to any concerns which have also received financing
from Associates (as defined in 13 CFR Section 107.50) except for the following:

____________________________________________________________________________________
4.
No assets of the licensee were pledged or otherwise hypothecated as security for any liability
except:

____________________________________________________________________________________
5.
No licensee capital stock (or licensee partnership interest) was pledged or encumbered except:

____________________________________________________________________________________
6.
The licensee is guaranteeing the following portfolio company loans: (List name of company,
amounts guaranteed, and payments made.)

____________________________________________________________________________________
7.
Outstanding financing commitments are:

____________________________________________________________________________________
8.
The licensee or its Associates provided management consultant services, technical services, or
any of the services of the type described in 13 CFR Section 107.900, to the following portfolio
companies:
NAME OF PORTFOLIO COMPANY

NAME OF SERVICE
PROVIDER (LICENSEE OR
ASSOCIATE)

SBA FORM 856 (5/15) REF SOP 10 09 PREVIOUS EDITIONS ARE OBSOLETE

DATE SERVICES
BEGAN

DESCRIPTION OF
FEES PAID BY
PORTFOLIO
COMPANY

2
___________________________________________________________________________________
9.
The licensee or its Associates assumed control over the following portfolio companies:

___________________________________________________________________________________
10.
The licensee’s Associates are also officers, directors, or employees (or partners) of portfolio
companies as follows:
NAME OF PORTFOLIO COMPANY

NAME OF ASSOCIATE

POSITION IN
PORTFOLIO COMPANY

DATE POSITION
TAKEN

___________________________________________________________________________________
11.
The licensee’s Associates have direct or indirect financial interest
in portfolio companies as follows:
NAME OF PORTFOLIO COMPANY AND
DESCRIPTION OF FINANCIAL INTEREST,
STOCK OWNERSHIP, WARRANTS,
PARTNERSHIP INTEREST, LOAN, ETC.

DATE FINANCIAL
INTEREST
ACQUIRED

COST BASIS

NAME OF ASSOCIATE

___________________________________________________________________________________
12.
The licensee’s Associates received title to or use of (with or without financial consideration)
assets from portfolio companies or from the licensee as follows:

WARNING By signing below, you are certifying as to the accuracy of information you have provided on or with this
statement. You are further 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, 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.

I hereby certify that all information provided in this disclosure statement, and all information and
documents that I have provided along with this disclosure statement, are true and correct to the best of
my knowledge.

____________________________________________
SIGNATURE AND TITLE

_______________________________
DATE

PLEASE NOTE: The estimated burden for completing this form, including gathering and complying the information, is 60 minutes.
You are not required to respond to any collection of information unless it displays a currently valid OMB approval number.
Comments on the burden should be sent to 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 Approval (3245-0118). PLEASE DO NOT SEND FORMS
TO OMB.