SBA Form 480 Size Status Declaration

OMB Approval No. 3245-0009

Expiration Date XX/XX/XXXX

U .S. SMALL BUSINESS ADMINISTRATION

SIZE STATUS DECLARATION

Use of Information. The information requested below will be used by SBA to determine the Applicant’s (“Applicant”) eligibility to receive financing or consulting and advisory services from a small business investment company licensed by SBA (“Licensee”). Applicants are required to complete this form prior to SBIC financing and associated management services. The SBIC must certify that the Applicant meets current size standards based on all the information available to the SBIC. Since the information is required to determine Applicant’s eligibility to receive SBIC Program assistance, failure to complete the form would impair its ability to receive that assistance. Instructions for submitting completed form. The Applicant should complete Part A and Part B (if necessary), sign the Applicant’s certification, and return the form to the Licensee from whom it is seeking assistance. The Licensee should sign the Licensee’s certification and retain the form in its files. SBA may request the completed form during an on-site examination of the Licensee.
Name and address of Licensee:				Name and address of Applicant:
___ ___ ___ Applicant’s Form of Organization: Corporation Partnership Limited Liability Company ___ Proprietorship
PART A
Yes No D oes the Applicant business have any Affiliates? If yes, attach a list to this form. Affiliation exists when one individual or entity controls or has the power to control another or when a third party or parties controls or has the power to control both. SBA considers factors such as ownership, management, previous relationships with or ties to another entity, and contractual relationships when determining whether affiliation exists.  The complete definition of affiliation is found at 13 CFR 121.103. (See also, 13 CFR 121.107 and 121.301.) Examples of Affiliates include: (1) a parent company; (2) subsidiaries and other companies that are owned or controlled by the Applicant; (4) companies under common management with the Applicant; and, (5) companies that have entered into agreements to merge with the Applicant. Additional guidance on affiliation can be found on SBA’s size standards website at http://www.sba.gov/size.   Does Applicant (including affiliates) have tangible net worth in excess of $24,000,000? (Tangible net worth = total net worth minus goodwill) Does Applicant (including affiliates) have average net income after Federal income taxes (excluding any carry-over losses) for the preceding 2 completed fiscal years in excess of $8,000,000? ___ ___
PART B
Applicant must complete this part only if the answer to question (2) or (3) in Part A was “Yes”. Applicant must not exceed the size standard for (1) the industry in which the Applicant combined with its affiliates is primarily engaged, and (2) the industry in which the Applicant alone is primarily engaged. Find the appropriate industry size standard under the NAICS code for your primary industry in 13 CFR 121.201.
Primary industry (include NAICS code): Applicant combined with affiliates__________________ Applicant alone__________________
Total annual receipts of Applicant (excluding affiliates):
2a. Select whether the Applicant elects to use a 3-year or a 5-year averaging period for average annual receipts: ____ 3-year average ____ 5-year average
2b.Total annual receipts of Applicant (excluding affiliates) for each of its most recently completed 5 fiscal years (divided by 5) as of the date that size is being determined (see 13 CFR 121.104). If selecting a 3-year average in (2a), only provide the most recently completed 3 fiscal years (divided by 3).
Yr.___________ Yr.___________ Yr.___________ Yr.___________ Yr.___________ Average		$____________ $____________ $____________ $____________ $____________ $____________
If a concern has been in business for less than 3 complete fiscal years, provide the total receipts for the period the concern has been in business, divided by the number of weeks in business, multiplied by 52. $_____________ / # weeks__________ X 52 = $_____________
Applicant’s average number of employees (excluding affiliates) based on the number of persons employed on a full-time, part-time, temporary, or other basis during each of the pay periods of the preceding 24 calendar months (see 13 CFR 121.106): ________________________
Affiliates of Applicant (domestic and foreign) Names and full addresses			Total annual receipts of affiliates (excluding Applicant) for each of its most recently completed 5 fiscal years as of the date that size is being determined. If selecting a 3-year average, only provide the most recently completed 3 fiscal years.			Average no. of persons employed by affiliates (excluding Applicant) on full-time, part-time, temporary, or other basis during each of the pay periods of the preceding 24 calendar months.
a.			Yr.___________ Yr.___________ Yr.___________ Yr.___________ Yr.___________ Average		$____________ $____________ $____________ $____________ $____________ $____________
b.			Yr.___________ Yr.___________ Yr.___________ Yr.___________ Yr.___________ Average		$____________ $____________ $____________ $____________ $____________ $____________
c.			Yr.___________ Yr.___________ Yr.___________ Yr.___________ Yr.___________ Average		$____________ $____________ $____________ $____________ $____________ $____________

Applicant’s Certification
Applicant, through its duly authorized officer, hereby certifies that all information herein and in attachments hereto is true and complete to the best of its knowledge and belief. Applicant further certifies that it intends to conduct, for a period of not less than 1 year from the date of the final disbursement of the funds involved in the subject financing and for a period of not less than 1 year from the date of the commencement of the consulting or advisory services, as a regular and continuous business operation, the business operation for which the application for financing or consulting or advisory services is being made. WARNING: By signing below, you are acknowledging that the U.S. Small Business Administration (SBA) is relying on this information, and that false statements can lead to criminal prosecution under 18 U.S.C. § § 1014, 1031, 3571, and other statutes, with fines in excess of $1,000,000 and imprisonment of up to 30 years, and civil fraud damages of three times the Government’s loss.
Name of Applicant:
Date:	By: (Signature of Officer)	Title:
Licensee’s Certification
Based upon all the information available to us, including all information and facts obtained through our own investigation, the Licensee has concluded that the Applicant is a small business concern within the requirements of the Small Business Investment Act of 1958, as amended, and the Regulations of SBA thereunder. WARNING: By signing below, you are acknowledging that the U.S. Small Business Administration (SBA) is relying on this information, and that false statements can lead to criminal prosecution under 18 U.S.C. § § 1014, 1031, 3571, and other statutes, with fines in excess of $1,000,000 and imprisonment of up to 30 years, and civil fraud damages of three times the Government’s loss.
Licensee Name:
Date:	By: (Signature of Authorized Official)	Title:

PLEASE NOTE: The estimated burden for completion of this form, including gathering the information and completing and reviewing the response, is 10 minutes. You are not required to respond to this information collection unless a valid OMB control number is displayed. The number for this collection of information is 3245-0009. If you have any questions or comments concerning this estimate or other aspects of this information collection, please contact the U.S. Small Business Administration, Director, Records Management Division, 409 3rd Street, S.W., Washington, DC 20416, and/or SBA Desk Officer, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, DC 20503. PLEASE SUBMIT OR RETAIN THE COMPLETED FORM ACCORDING TO THE INSTRUCTIONS ABOVE. PLEASE DO NOT SEND FORMS TO OMB.

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SBA Form 480 (X-XX) Previous Editions Obsolete