Form SBA Form 857 SBA Form 857 Request for Information Concerning Portfolio Financing

OMB Approval No. 3245-0109
Expiration Date: XX/XX/XXXX

U.S. SMALL BUSINESS ADMINISTRATION (SBA)
REQUEST FOR INFORMATION CONCERNING PORTFOLIO FINANCING
BY SMALL BUSINESS INVESTMENT COMPANIES (SBICs)
______________________________________________________________________________________________________________________________________________________________________________________________________________

The information requested below obtains voluntary representations from the management of small businesses
receiving financing from Small Business Investment Companies (SBICs) to assist in SBA’s oversight of the SBIC
program. The information is collected by an SBA Examiner as part of an examination to determine SBIC compliance
with applicable statutory and regulatory requirements, including, but not limited to: conflicts of interests, maximum
interest rates, use of financing proceeds, and verification of information reported to SBA regarding financing activities.
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.
Please return completed form to the address provided in the cover correspondence from the requesting SBA
Examiner, within 10 days of receipt or as otherwise directed by the Examiner.
______________________________________________________________________________________________________________________________________________________________________________________________________________

Name of SBIC__________________________________________________________
Name of Small Business__________________________________________________
1. Describe the type(s) of investments(s) (e.g. senior loan, subordinated loan, preferred stock, etc.),
terms, and the unpaid balance(s) of financing(s) your company received from the SBIC.

2. Does the SBIC own an equity interest in your company (shares of stock, partnership interest, etc.)?
Yes____ No____
If ‘Yes’ please indicate the number of shares, the percentage of ownership, and the purchase price
paid for such equity interest:

3. Have any warrants or options for equity interests been issued by your company to the SBIC?
Yes____ No____
If ‘Yes’ what are the terms and the conditions of these instruments, including dates, number of
shares, prices, etc.?

4. How were the proceeds of this financing used by your company?

5. Are any of the officers, directors or owners of your company related to or affiliated in any way with:
(a) The SBIC or its officers, directors or owners? Yes____ No____
(b) Any other SBIC or its officers, directors or owners? Yes____ No____
If the answer to either question above is ‘Yes’ please furnish details:

SBA Form 857 (XX/XX) Previous Editions Obsolete

6. Who were the officers, directors and/or owners of your company at the time of the financing?

7. Were any application, closing, or financing fees, or expense reimbursements paid by your company
in connection with this financing? If ‘Yes’ please describe the types of fees and expenses, the
amounts paid, and the recipient of the payments.

8. Has the SBIC or any person or entity affiliated with the SBIC provided management consultant
services, technical services, or services as a member of the board of directors to your company? If
‘Yes’ please indicate the nature of such services and what, if any, fees were paid by your company
in connection with those services.

9. Any other comments or concerns you consider pertinent to SBA’s examination:

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, 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 form is true and correct to the best of my knowledge.

____________________________________________
SIGNATURE AND TITLE

_______________________________
DATE

___________________________________________
SMALL BUSINESS NAME

PLEASE NOTE: The estimated burden for completing this form is 1.25 hours. You are not required to respond to this or 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
3245-0109).

SBA Form 857 (XX/XX) Previous Editions Obsolete