Form SBA Form 912 SBA Form 912 Statement of Personal History

OMB APPROVAL NO.3245-0178
Expiration Date: 05/31/2019

United States of America
SMALL BUSINESS ADMINISTRATION
STATEMENT OF PERSONAL HISTORY

Please Read Carefully and Fully Complete: SBA uses Form 912 as one part
of its assessment of program eligibility. Please reference SBA Regulations and
Standard Operating Procedures if you have any questions about who must
submit this form and where to submit it. For further information, please call
SBA's Answer Desk at 1-800-U-ASK-SBA (1-800-827-5722), or check SBA's
website at www.sba.gov. DO NOT SEND COMPLETED FORMS TO OMB as
this will delay the processing of your application; send forms to the address
provided by your lender or SBA representative.

1a. Name and Address of Applicant (Firm Name)(Street, City, State, ZIP Code and E-mail) SBA District/Disaster Area Office

File No. (if known)

Amount Applied for (when applicable)
1b. Personal Statement of: (State name in full, if no middle name, state (NMN), or if initial
only, indicate initial.) List all former names used, and dates each name was used.
Use separate sheet if necessary.
First

Middle

Last

2. Give the percentage of ownership in the small
business

Social Security No.

3. Date of Birth (Month, day, and year)

4. Place of Birth: (City & State or Foreign Country)

5. U.S. Citizen?
YES
If no, are you a Lawful
Permanent resident alien?

If applicable, Name and Address of participating lender or surety co.

NO
YES

INITIALS:
NO

Alien Registration number
If no, country of citzenship:
Most recent prior address (omit if over 10 years ago):

6. Present residence address:
From:

From:

To:
Address:

To:
Address:

Home Telephone No. (Include Area Code):
Business Telephone No. (Include Area Code):

PLEASE SEE REVERSE SIDE FOR EXPLANATION REGARDING DISCLOSURE OF INFORMATION AND THE USES OF SUCH INFORMATION.
YOU MUST INITIAL YOUR RESPONSES TO QUESTIONS 5,7,8 AND 9.
IF YOU ANSWER "YES" TO 7, 8, OR 9, YOU MUST FURNISH DETAILS ON A SEPARATE SHEET. INCLUDE DATES, LOCATION, FINES, SENTENCES,
MISDEMEANOR OR FELONY, DATES OF PAROLE/PROBATION, UNPAID FINES OR PENALTIES, NAME(S) UNDER WHICH CHARGED, AND ANY
OTHER PERTINENT INFORMATION. AN ARREST OR CONVICTION RECORD WILL NOT NECESSARILY DISQUALIFY YOU; HOWEVER, AN
UNTRUTHFUL ANSWER WILL CAUSE YOUR APPLICATION TO BE DENIED AND SUBJECT YOU TO OTHER PENALTIES AS NOTED BELOW.
7. Are you presently subject to an indictment, criminal information, arraignment, or other means by which formal criminal charges are brought in any jurisdiction?
Yes

No

INITIALS:

8. Have you been arrested in the past six months for any criminal offense?
Yes

No

INITIALS:

9. For any criminal offense – other than a minor vehicle violation – have you ever:1) been convicted; 2) pleaded guilty; 3) pleaded nolo contendere; 4) been placed on pretrial diversion;
or 5) been placed on any form of parole or probation (including probation before judgment).
INITIALS:
Yes
No
10. I authorize the Small Business Administration to request criminal record information about me from criminal justice agencies for the purpose of
determining my eligibility for programs authorized by the Small Business Act and the Small Business Investment Act.
CAUTION - PENALTIES FOR FALSE STATEMENTS: Knowingly making a false statement on this form is a violation of Federal law and could result in criminal prosecution,
significant civil penalties, and a denial of your loan, surety bond, or other program participation. A false statement is punishable under 18 USC 1001 and 3571 by imprisonment of not
more than five years and/or a fine of up to $250,000; under 15 USC 645 by imprisonment of not more than two years and/or a fine of not more than $5,000; and, if submitted to a
Federally insured institution, under 18 USC 1014 by imprisonment of not more than thirty years and/or a fine of not more than $1,000,000.
Signature

Title

Agency Use Only
11.

Fingerprints Waived
Fingerprints Required

Date Sent to OPS

Date

Approving Authority

Date

Approving Authority

SBA 912 (5-2019) SOP 5010 Previous Edition Obsolete

Date

12.

Cleared for Processing

13.

Request a Character Evaluation

Date

Approving Authority

Date

Approving Authority

(Required whenever 7, 8 or 9 are answered "yes" even if cleared for processing.)

NOTICES REQUIRED BY LAW

Paperwork Reduction Act (44 U.S.C. Chapter 35)
PLEASE NOTE: The estimated time for completing this request for information, including time for
reviewing instructions, gathering the information needed, and completing and reviewing your
responses, is 15 minutes. You are not required to respond to this collection of information unless it
displays a currently valid OMB Approval Number. The number for this collection of information is 32450178. If you wish to submit comments on the estimated completion time or any other aspect of this
collection of information, direct these comments to: Small Business Administration, Director, Records
Management Division, 409 3rd St., S.W., Washington D.C. 20416 and/or Desk Officer for the Small
Business Administration, Office of Management and Budget, New Executive Office Building, Room
10202, Washington, D.C. 20503.

Privacy Act Statement ( 5 U.S.C. 552a)
Purpose for Collecting Information: SBA is collecting the information on this form, including your social
security number and other personal information to make a character and credit eligibility decision in
connection with you or your company’s application for a loan or other form of SBA assistance.
Submission of the requested information is voluntary; however, because the information is required in
order for SBA to have sufficient information to determine whether to provide you with the requested
assistance, if you do not provide the information, we would be unable to make a final decision on your
application.
Authorities: Under the Privacy Act, 5 U.S.C. § 552a, failure to provide your social security number may
not affect any right, benefit or privilege to which you are entitled. However, disclosures of name and
other personal identifiers are required for a benefit, as SBA requires an individual seeking assistance
from the Agency to provide it with sufficient information 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. SBA is specifically authorized to verify your criminal history, or
lack thereof, pursuant to section 7(a)(1)(B) of the Small Business Act, (the SBAct), 15 USC § 636(a)(1)(B).
Additionally, in making loans pursuant to section 7(a)(6) the SBAct, 15 USC § 636 (a)(6), SBA is required
to have reasonable assurance that the loan is of sound value and will be repaid or that it is in the best
interest of the Government to grant the assistance requested. Further, 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 SBAct or Small Business Investment Act,15 USC §§ 634(b)(11) and 687b(a). For
these purposes, you are asked to voluntarily provide your social security number to assist SBA when
making a character determination to distinguish you from other individuals with the same or similar
name, date of birth or other personal identifier. This request is permitted under EO 9397.
Routine Uses: The information collected may be checked against criminal history indices of the Federal
Bureau of Investigation. When the information collected indicates a violation or potential violation of
law, whether civil, criminal, or administrative in nature, SBA may refer it 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. See, SBA’s Privacy Act System
of Records, at 74 Fed. Reg. 14890 (2009), as amended for other published routine uses for the collected
information.

SBA Form 912(5/2019) Previous Edition Obsolete.