Form SBA Form 1081 SBA Form 1081 Statement of Personal History

OMB APPROVAL NO.: 3245-0080

EXPIRATION DATE: XX-XX-2023

U.S. Small Business Administration STATEMENT OF PERSONAL HISTORY (FOR USE BY LENDERS)			Please Read Carefully and Fully Complete: SBA uses the Form 1081 to determine the eligibility of an individual to participate in SBA Loan Programs. Please reference SBA Regulations and Standard Operating Procedures if you have any questions about who must submit this form and where to submit it. Do not send completed forms to OMB as that will delay the processing of your application; send forms to SBA.
Lender Name Lender Type: CDC Microlender SBLC CDFI NFRL Other
Lender Address (Street, City, State, Zip Code); Email Address and Telephone Number
1. First Name Middle Name (if none, so state) Last Name
2. Date of Birth (month, day & year)	3. Place of Birth (City and State or Foreign Country)
4. U.S. Citizen? Yes No INITIALS: If no, are you a Lawful Permanent Resident Alien? Yes No Alien Registration Number: If no, Country of Citizenship:		5. Social Security Number:
6. Starting with present address, attach a list of residence addresses for the last ten years using the following format: From (Date) To (Date) Address
7. Employment, Professional History and Education: Attach a resume that provides a summary of: (a) your business or professional experience during the last ten years up to and including the present, stating the periods of each primary activity; the names, addresses and nature of business of the concerns with which you associated; title and position in such concerns; and your basic functions and responsibilities in such concerns; (b) a summary of your education showing highest level attained (such as high school graduate, bachelor's degree, master's degree, etc., and giving, when applicable, the name of the higher educational institution, your specialization, and date of degree); (c) a summary of any special experience or qualifications pertinent to your responsibilities in connection with the management or operation of all lenders and (d) identify and relate your business and professional experience during the past ten years to your qualifications to direct the management, policies or operations of an SBA Lender or SBA Microloan Intermediary (as defined in 13 CFR 120.10).
8. Present Affiliations and/or Associations: Attach a list of all business concerns or entities with which you are presently Affiliated (as defined in 13 CFR §121.103), and/or Associated (as defined in 13 CFR §120.10), or in which you have direct or indirect ownership or control of 10% or more of any class of stock or proprietary interest. Include the names, addresses, and nature of business of such concerns or entities, and provide the details of your relationships and ownership, including the percentage ownership of any stock, equity, voting, profit or proprietary interest owned.

IF YOU ANSWER “YES” TO 9a., 9b., 10a., 10b., 10c., 11a., 11b. or 12, FURNISH COMPLETE DETAILS OF SUCH PROCEEDINGS ON A SEPARATE SHEET. INCLUDE DATES, LOCATIONS, FINES, SENTENCES, WHETHER MISDEMEANOR OR FELONY, DATES OF PAROLE/PROBATION, INCLUDING, IF PERTINENT, THE COURT, TITLE OF PROCEEDINGS, DATE AND DOCKET NUMBER, AS WELL AS THE ULTIMATE DISPOSITION.
YES	NO	9a. Have you, or has any business concern or entity with which you are or have been Affiliated or Associated (as defined above), ever been, directly or indirectly, the subject of any insolvency, bankruptcy, creditor's rights proceedings (including Federal or state tax liens), or other litigation?
		9b. Have you, or has any business concern or entity with which you are or have been Affiliated or Associated (as defined above) ever failed to pay when due any debt or obligation, including any amounts in dispute, to the Federal government or guaranteed by the Federal government (including but not limited to taxes, business and student loans)?
		10a. Are you presently subject to an indictment, criminal information, arraignment, or other means by which formal criminal charges are brought in any jurisdiction?
		10b. Have you been arrested in the past six months for any criminal offense?
		10c. For any criminal offense – other than 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)?
		11a. Have you, or has any business concern or entity with which you are or have been Affiliated or Associated (as defined above), ever been charged with or convicted of a felony or other criminal offense involving fraud, misrepresentation, dishonesty or breach of trust?
		11b. Have you, or has any business concern or entity with which you are or have been Affiliated or Associated (as defined above) ever been a named defendant in any civil legal action (including shareholder litigation), found civilly liable, or permanently or temporarily enjoined by a court or other regulatory body, by reason of any act or practice involving fraud, misrepresentation, breach of fiduciary duty or breach of trust?
		Have you, or has any business concern or entity with which you are or have been Affiliated or Associated (as defined above) ever been: Debarred, suspended, proposed for debarment, declared ineligible to participate in, or voluntarily excluded or revoked from Federal procurement programs and/or Federal non-procurement programs; The subject of any suspension, debarment, voluntary exclusion, revocation, or any other regulatory enforcement action by a state or federal agency, or any other regulatory enforcement body; The subject of any other decision by a federal, state or local governmental agency undertaking administrative enforcement due to fraud, lack of business integrity, ethics violations, or noncompliance with other governmental requirements; or The subject of any investigation or disciplinary hearing or proceeding by a governmental agency, regulatory body, or professional association?
		13. Are you associated with any other SBA Lender, SBA Microloan Intermediary, Agent or Lender Service Provider (as those terms are defined in 13 CFR 103.1 and 13 CFR 120.10)? Are you, or have you been, a direct or indirect owner of 10% or more of any class of stock, equity interest, voting interest, profit interest, or proprietary interest in any past or present SBA Lender, SBA Microloan Intermediary, Agent or Lender Service Provider? Are you, or have you been, an officer, director, member of senior management, manager or member of a loan committee of any past or present SBA Lender, SBA Microloan Intermediary, Agent or Lender Service Provider? The term “senior management” generally refers to an individual’s meaningful participation in the direction of the operations, policies or financial decisions of a business concern or entity. (If the answer to any of the foregoing is “yes,” please provide the name of the SBA Lender, SBA Microloan Intermediary, Agent or Lender Service Provider, your positions, basic functions and responsibilities, and the dates.)
		14. During any part of the past ten years has a request for financial assistance been made to any federal agency by you or any business concern or entity with which you are or have been Affiliated or Associated (as defined above)? (If yes, furnish details in a separate exhibit, including current status of any assistance received.)

YES	NO	15. To your knowledge, is any SBA employee, any member of an Advisory Council for the Small Business Administration, or any member of SCORE related to you by blood, marriage, or adoption, or through an Affiliate or Associate of yours (as defined above)? (If yes, list their names, addresses, and relationship to you.)
		16. If you own, or will own 10% or more of any class of the stock or other ownership interest of an SBA Lender or SBA Microloan Intermediary did you borrow funds to purchase said interest? (If yes, give full details including your net worth, amount borrowed or to be borrowed, security and/or guarantors, terms of repayment, and status of loan/debt.)
		17. Has any concern with which you are Affiliated or Associated (as defined above) directly or indirectly borrowed funds from any SBA Lenders, or SBA Microloan Intermediaries? (If yes, give all pertinent details including the names of all parties to the transaction, the amounts involved, security and/or guarantors, terms of repayment, use of proceeds, status of loan/debt, etc.)

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.

The information on this form will be used in connection with an investigation of your experience and character. It is against SBA policy to provide assistance not in the best interests of the United States, i.e., if there is reason to believe that the effect of such assistance will be to encourage or support, directly or indirectly, activities inimical to the security of the United States.

The nature and scope of the investigation may include contact with banks, other financial institutions, individuals, business associates, law enforcement offices, and any other individual or entity that will assist SBA in making an adequate appraisal of your business reputation, character, management experience and financial soundness. This constitutes the notification required by Section 606 of the Federal Fair Credit Reporting 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 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 not more than $250,000; and under 15 USC 645 by imprisonment of not more than two years and/or a fine of not more than $5,000.

Certification: I hereby certify that the foregoing is true and complete to the best of my knowledge and belief.

Signature Title Date

PLEASE NOTE: The estimated burden for completing this form is 30 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, Chief, AIB, 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 (3245-0080). DO NOT SEND COMPLETED FORMS TO OMB as that will delay the processing of your application.

Paperwork Reduction Act (44 U.S.C. Chapter 35) (USE OFINFORMATION)

SBA is collecting the information on this form to make a character determination regarding Associates of Lenders and other individuals or entities that propose to hold an equity interest of at least 10% of the economic interest in certain Lenders. An Associate is defined as an officer, director, key employee, or holder of 20 percent or more of the value of the Lender’s stock or debt instruments, or an agent involved in the loan process (13 CFR §120.10, Definitions). The information also provides the Agency with background data which is evaluated to determine if the institution’s key personnel have sufficient qualifications in commercial lending activities. The information collected may be checked against criminal history indices of the Federal Bureau of Investigation.

Privacy Act (5 U.S.C. 552a)

Anyone can request to see or get copies of an individual’s personal information that SBA has in its records. However, personal information in your file, such as name or social security number is protected by the Privacy Act, which means that requests for an individual’s personal information 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.

The Privacy Act authorizes SBA to make certain “routine uses” of information protected by that Act. Based on one such routine use, if information in an SBA system of records indicates a violation or potential violation of law, whether civil, criminal, or administrative in nature, 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), as amended from time to time, for additional background and other routine uses.

Under the Privacy Act, you are not required to provide your social security number and failure to provide it 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. Additionally, SBA is specifically authorized to verify your criminal history, or lack thereof, pursuant to section 7(a)(1)(B), 15 USC Section 636(a)(1)(B) of the Small Business Act (the Act). 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 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.

Freedom of Information Act (5 U.S.C. 552)

This law provides, with some exceptions, that SBA must supply information reflected in agency files and records to a person requesting it. Information about approved loans that will be automatically released includes, among other things, statistics on our loan programs (individual borrowers are not identified in the statistics) and other information such as the names of the borrowers (and their officers, directors, stockholders or partners), the collateral pledged to secure the loan, the amount of the loan, its purpose in general terms and the maturity.

Proprietary data on a borrower would not routinely be made available to third parties. All requests under this Act are to be addressed to the nearest SBA office and be identified as a Freedom of Information request.

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SBA Form 1081 (12-19) Previous Editions Obsolete