SBA Form 856A DISCLOSURE STATEMENT NON-LEVERAGED LICENSEES

O MB CONTROL NO. 3245-0118

EXPIRATION DATE XX/XX/XX

U.S. SMALL BUSINESS ADMINISTRATION (SBA)

DISCLOSURE STATEMENT

NON-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. Providing this information is required for compliance with 13 CFR § 107.691. Failure to do so may subject the SBIC to fees as authorized by 13 CFR §107.692. Please return completed forms as directed by the requesting SBA Examiner.

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

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2. 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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3. The licensee or its Associates provided management consultant services, technical services, services as a member of the board of directors or any of the services of the type described in 13 CFR Section 107.900, to the following portfolio companies:

NAME OF PORTFOLIO COMPANY	NAME OF SERVICE PROVIDER (LICENSEE OR ASSOCIATE)	DATE SERVICES BEGAN	DESCRIPTION OF FEES PAID BY PORTFOLIO COMPANY

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4. The licensee or its Associates assumed Control (as defined in 13 CFR Section 107.50) over the following portfolio companies:

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5. 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

SBA FORM 856A (XX/XX) REF SOP 10 09 PREVIOUS EDITIONS ARE OBSOLETE

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

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

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7. 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