SBA Form 856A Disclosure Statement Non-Leveraged Licensees

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

U.S. SMALL BUSINESS ADMINISTRATION (SBA)
DISCLOSURE STATEMENT
NON-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 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.
No litigation was in progress or pending, or is now in progress or pending, except for the
following:

____________________________________________________________________________________
2.
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:

____________________________________________________________________________________
3.
The licensee or its Associates provided management consultant services, technical services, or
any of the services of the type described in 13 CFR 107.900, to the following portfolio companies:
NAME OF PORTFOLIO COMPANY

NAME OF SERVICE
PROVIDER (LICENSEE OR
ASSOCIATE)

DATE SERVICES
BEGAN

DESCRIPTION OF
FEES PAID BY
PORTFOLIO
COMPANY

____________________________________________________________________________________
4.
The licensee or its Associates assumed control over the following portfolio companies:

____________________________________________________________________________________
5.
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

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

___________________________________________________________________________________

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6.

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

___________________________________________________________________________________
7.
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 is 45 minutes per response. 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.