SBA FORM 856 Disclosure Statement Leveraged Licensees; Dislosure Stat

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O MB CONTROL NO. 3245-0118

EXPIRATION DATE XX/XX/XX

U.S. SMALL BUSINESS ADMINISTRATION (SBA)

DISCLOSURE STATEMENT

LEVERAGED LICENSEES

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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 onsite examination of the SBIC. Please return completed forms as directed by the requesting SBA Examiner.

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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.)

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1. All known liabilities of this licensee were recorded on the books of account except for the following:

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2. No litigation was in progress or pending, or is now in progress or pending, except for the following:

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3. 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:

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4. No assets of the licensee were pledged or otherwise hypothecated as security for any liability except:

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5. No licensee capital stock (or licensee partnership interest) was pledged or encumbered except:

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6. The licensee is guaranteeing the following portfolio company loans: (List name of company, amounts guaranteed, payments made.)

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7. Outstanding financing commitments are:

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8. The licensee or its Associates provided management consultant services or technical services to the following portfolio companies:

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

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SBA FORM 856 (5/12) REF SOP 90 35 PREVIOUS EDITIONS ARE OBSOLETE

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10. 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

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11. The licensee’s Associates have direct or indirect financial interest in portfolio companies as follows:

NAME OF PORTFOLIO COMPANY AND DISCRIPTION OF FINANCIAL INTEREST, STOCK OWNERSHIP, WARRANTS, PARTNERSHIP INTEREST, LOAN, ETC.	DATE FINANCIAL INTEREST ACQUIRED	COST BASIS	NAME OF ASSOCIATE

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12. 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. 

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SIGNATURE AND TITLE DATE

PLEASE NOTE: The estimated burden for completing this form is 30 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, Chief, AIB, 409 3^rd 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.