SBA Form 770 Financial Statement of Debtor

OMB NO: 3245-0012
Expiration Date: xx/xx/xxxx

U.S. Small Business Administration
FINANCIAL STATEMENT OF DEBTOR
(INSERT THE WORD “NONE” WHERE APPLICABLE TO ANY OF THE FOLLOWING ITEMS)
1. NAME

SBA LOAN NUMBER

2. DATE OF BIRTH (Month, Day and Year)

3. ADDRESS (Include ZIP Code)

4. PHONE NO.

6. OCCUPATION

7. HOW LONG IN PRESENT EMPLOYMENT?

8. EMPLOYER’S NAME

9. MONTHLY INCOME:
Salary or wages
Commissions
Other (state source)
Total

ADDRESS (Include ZIP Code)

PHONE NUMBER

10. OTHER EMPLOYERS WITHIN LAST 3 YEARS
$_____________

Name

Address

Dates of Employment

$_____________
$_____________
$_____________

11. NAME OF SPOUSE

SOCIAL SEC. NO.

12. DATE OF BIRTH (Month, Day and Year)

13. OCCUPATION

14. HOW LONG IN PRESENT EMPLOYMENT?

15. SPOUSE’S EMPLOYER (Name)

16. MONTHLY INCOME OF SPOUSE:
Salary or wages
Commissions
Other (state source)
Total

5. SOCIAL SEC. NO.

ADDRESS (Include ZIP Code)

PHONE NUMBER

17. OTHER EMPLOYERS WITHIN LAST 3 YEARS (Of Spouse)
$_____________

Name

Address

Dates of Employment

$_____________
$_____________
$_____________

18. OTHER DEPENDENTS: ______ NUMBER

23. FIXED MONTHLY EXPENSES: (TO NEAREST DOLLAR)

Name

Relationship

Age

Rent or House Payment

$_________________

Utilities

$_________________

Food

$_________________

Interest

$_________________

Insurance

$_________________

Debt Repayments:
Household furnishings

$_________________

Personal Loans

$_________________

Automobile

$_________________

20. FOR WHAT PERIOD DID YOU LAST FILE A FEDERAL INCOME TAX RETURN?

Doctors and Dentist

$_________________

21. WHERE WAS TAX RETURN FILED?

Other (Specify)

$_________________

19. TOTAL MONTHLY INCOME OF DEPENDENTS (Except Spouse)

22. AMOUNT OF GROSS INCOME REPORTED

$

$

NOTE: USE ADDITIONAL SHEETS WHERE SPACE ON THIS FORM IS INSUFFICENT
SBA Form 770 (12-14) REF SOP 50-57 and 50-52 Previous Editions Obsolete

TOTAL FIXED MONTHLY EXPENSES

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$

24. ASSETS AND LIABILITIES (SHOW AMOUNTS TO THE NEAREST DOLLAR)
ASSETS: (Fair Market Value)

LIABILITIES
$

Cash
Checking Accounts: (Show location)

$

Bills owed (grocery, doctor, lawyer, etc.)

$

Installment debt (car, furniture, clothing, etc.)

$

Taxes Owed:

$

Savings Accounts: (Show location)

Income

$

Other (itemize)

$

$

$

$

Loans payable (to banks, finance companies, etc.)

$

Cash Surrender Value of Life Insurance

$
$

Motor Vehicles:
Make

Year

License No.

Judgments you owe (Held by whom?)
$

$

$

$

Small Business Administration

$

$

Loans of Life Insurance

$

$

Mortgages of Real Estate

Debts owed to you: (Name of debtor)

$

Stocks, bonds, and other securities:
$

$

$

$

Household furniture and goods

$

Margin Payable on Securities

Items Used in Trade or Business

$

Other Debts (Itemize)

$

$

Other Personal Property (Itemize)
$

$

$

$
$

Real Estate (Itemize)
$

$

$

Other Assets (Itemize)
$

Total Liabilities

$

Net Worth

$

CONTINGENT LIABILITIES

$

$
$

TOTAL ASSETS:

25. LOANS PAYABLE
Owed To:

Date of Loan

26. REAL ESTATE OWNED (Free & Clear): Address

Original Amount

Present Balance

Terms of Repayments

$

$

$

$

$

$

$

$

$

How Owned (Jointly, individually, etc.)

Present Market Value
$
$

NOTE: USE ADDITIONAL SHEETS WHERE SPACE ON THIS FORM IS INSUFFICENT
SBA Form 770 (12-14) REF SOP 50-57 and 50-52 Previous Editions Obsolete

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How Secured?

27. REAL ESTATE BEING PURCHASED ON

Date Acquired

CONTRACT OR MORTGAGE (Address)

Name of Seller or Mortgagor

28. LIFE INSURANCE POLICIES: Company

Balance Owed: $

Purchase Price $

Date Next Cash Payment Due

Present Market Value $

Amount of Next Cash Payment $

Face Amount

Cash Surrender Value

Outstanding Loans

$

$

$

$

$

$

$

$

$

29. LIST ALL REAL AND PERSONAL PROPERTY OWNED BY SPOUSE AND DEPENDENTS VALUED IN EXCESS OF $500:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
30. LIST ALL TRANSFERS OF PROPERTY, INCLUDING CASH (BY LOAN, GIFT, SALE, ETC.), THAT YOU HAVE MADE WITHIN THE LAST THREE YEARS. (LIST
ONLY TRANSFERS OF $500 OR OVER.)
Property Transferred

To Whom

Date

Amount
$
$
$

31. ARE YOU A CO-MAKER, GUARANTOR, OR A PARTY IN ANY LAW SUIT OR CLAIM NOW PENDING?
YES

NO

IF YES, GIVE DETAILS

32. ARE YOU A TRUSTEE, EXECUTOR, OR ADMINISTRATOR?

YES

NO

IF YES, GIVE DETAILS

33. ARE YOU A BENEFICIARY UNDER A PENDING, OR POSSIBLE, INHERITANCE OR TRUST, PENDING OR ESTABLISHED?
IF YES, GIVE DETAILS

34. WHEN DO YOU BELIEVE THAT YOU CAN START MAKING PAYMENTS
ON YOUR SBA DEBT?

YES

NO

35. HOW MUCH DO YOU BELIEVE THAT YOU CAN PAY SBA ON A
MONTHLY OR PERIODIC BASIS?

Under the provisions of 31 U.S.C. 7701, the applicant business and any guarantor of the loan are required to provide their social security numbers or other taxpayer
identification numbers in order to do business with SBA. The information is used in connection with the collection and reporting of amounts owed to the Agency
and facilitates credit determinations during the liquidation phase. SBA also uses the information pursuant to E.O. 9397 to help distinguish between persons with
the same or similar name.
By signing below, I certify that all statements made in this form, and all information provided with this form, are true and correct, I understand that SBA and my
lender are relying on this information, and that false statements can lead to criminal prosecution under 18 U.S.C. 1001 and other laws, with fines of up to
$500,000 and imprisonment up to 10 years, and civil fraud damages of three times the government’s loss.

SIGNATURE

DATE

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NOTE: USE ADDITIONAL SHEETS WHERE SPACE ON THIS FORM IS INSUFFICENT
SBA Form 770 (12-14) REF SOP 50-57 and 50-52 Previous Editions Obsolete

Purpose: The primary purpose for collecting this information is to evaluate the debtor’s financial capacity to repay the debt owed to
the Agency and determine to what extent the Agency may compromise the debt, maximize recovery, and protect the interests of the
Agency. Providing the requested information is voluntary. However, if the information is not provided, SBA would be unable to
fully consider your request for a compromise and may exercise its right to pursue immediate and full payment of the debt. Routine
uses of this information are established in SBA’s Privacy Act System of Record, SBA 21, Loan System published on April 1, 2009, at 74
FR 14890, as amended on October 9, 2012, at 77 FR 61467 and on March 16, 2012, at 77 FR 15830 and, SBA 20, Disaster Loan Case
File published on April 1, 2009, at 74 FR 14890. Any Person concerned with the collection of this information, its voluntariness,
disclosure or routine use under the Privacy Act may contact the Freedom of Information/Privacy Acts Office, Small Business
Administration, 409 3rd St., S.W., Washington, D.C. 20416.
Instruction for Non-Disaster loans: Forms are to be completed and signed by the obligor and then submitted to the lender. Lenders
are to submit the original copy (or scanned copy of the original) to the SBA servicing center handling the account. Retain a copy for
your files. The servicing centers are the National Guaranty Purchase Center located at 1165 Herndon Parkway, Suite 135, Herndon,
VA 20170, fax: 202-481-4674, email: [email protected]; the SBA Commercial Loan Service Center East located at 2120
Riverfront Drive, Suite 100, Little Rock, AR 72202, fax: 202-292-3878, email: [email protected]; and the SBA
Commercial Loan Servicing Center West located at 801 R Street, Suite 101, Fresno, CA 93721, fax: 202-481-0663, email:
[email protected].
Disaster Instructions: Forms are to be completed and signed by the Borrower/Obligor and then submitted to the SBA Disaster Loan
Servicing Center handling the account. Retain a copy for your files. The servicing centers are: Birmingham Disaster Loan Servicing
Center, 2 North 20th Street, Suite 320, Birmingham, AL 35203, fax: 202-481-0292, email: [email protected]; El Paso Disaster
Loan Servicing Center, 1545 Hawkins Boulevard, Suite 202, El Paso, TX 79925, fax: 915-633-7123, email: [email protected];
National Disaster Loan Resolution Center, 200 West Santa Ana Boulevard, Suite 740, Santa Ana, CA 92701, fax: 714-550-1164, email:
[email protected].

PLEASE NOTE: The estimated burden for completing this form is 1 hour. You are not required to respond to any collection of
information unless it displays a currently valid OMB approval number. Commitments on the burden should be sent to U.S. Small
rd
Business Administration, Director, Records Management Division, 409 3 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, DC
20503. OMB Approval (3245-0012). PLEASE DO NOT SEND FORMS TO OMB.

NOTE: USE ADDITIONAL SHEETS WHERE SPACE ON THIS FORM IS INSUFFICENT
SBA Form 770 (12-14) REF SOP 50-57 and 50-52 Previous Editions Obsolete

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