SBA Form 2181 SBIC Activities Relationship Certification

---

Overview

Notices Required by Law
Activities + SBIC Relationships
Certification

---

Sheet 1: Notices Required by Law

Notices Required by Law
The following is a brief summary of the laws applicable to this collection of information.

PAPERWORK REDUCTION ACT (44 U.S.C. Chapter 35)
Purpose for Collecting Information: The information requested in this Form 2181 (including, but not limited to, Exhibits A through G and the Management Assessment Questionnaire) will be used in connection with an investigation of your experience and character. The scope of this investigation may include contact with banks, other financial institutions, individuals, business associates, law enforcement offices (including the Federal Bureau of Investigation), and any others that will assist SBA in making an adequate appraisal of your general business reputation and character. SBA may also use the information to assist in obtaining credit bureau reports, including consumer credit reports and scores on the principals of the SBIC applicant, for the purpose of determining whether to approve a principal’s participation in the SBIC program. If information provided to SBA indicates a violation or potential violation of law, whether civil, criminal, or administrative in nature, SBA may refer it 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.

Personal information (Privacy Act, 5 U.S.C. 552a)
Any person can request to see or get copies of any personal information that is maintained by SBA. However, requests for information about another individual 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 (5 U.S.C. 552). Generally, you are not required to provide your social security number and the failure to provide your social security number generally may not affect any right, benefit or privilege to which you are entitled. However, the Debt Collection Improvement Act of 1996 (31 U.S.C. 7701(c)(1)) requires a Federal agency to obtain the taxpayer identification number (TIN) from each person doing business with that agency.). Therefore, it is mandatory that you furnish your TIN to the SBA as part of your licensing application. Additionally, disclosure of your name and other personal information requested is mandatory. SBA is required under Section 301(c)(3) of the Small Business Investment Act, 15 U.S.C. 681(c)(3), to consider the general business reputation of certain key individuals in order to make a determination about whether each individual has the business experience and character necessary to participate in the SBIC program. Your social security number and other personal identifiers assist SBA in making these determinations required by law. If you do not provide this information, SBA will be unable to reach a favorable determination concerning your participation in the SBIC program.

Freedom of Information Act (U.S.C. 552)
This law provides, with some exceptions, that we must make records or portions of records contained in our files available to persons requesting them. This generally includes aggregate statistical information on the SBIC program and other information such as names of licensed SBICs and names of companies that have been financed by SBICs. We do not routinely make available to third parties your proprietary data or information that would cause competitive harm or would constitute a clearly unwarranted invasion of personal privacy. We note that Exemptions, 4, 6 and 8 of the Freedom of Information Act (FOIA) allow SBA to withhold financial data on individual companies. To request information under FOIA, you must send the request to the SBA office maintaining the records requested or the Chief, FOI/PA Office, 409 3rd Street, SW, Washington, DC 20416, or by e-mail to [email protected], and identify it as a Freedom of Information Act (FOIA) request. The request must describe the specific records you want

---

Sheet 2: Activities + SBIC Relationships

Other Activities and SBIC Relationships

As of Date:

MM/DD/YYYY

This sheet should be completed by each principal or control person of the applicant.

Name of Applicant:

ABC SBIC, L.P.

1

If you own, or will own, 10% or more of the Private Capital (13 CFR 107.50) of the SBIC, were any of the funds used, or to be used, in purchasing said Private Capital, borrowed?

1.a

If “Yes”, give full details, including your net worth, amount borrowed or to be borrowed, source of funds borrowed or to be borrowed, terms of repayment, security and/or guarantors.

2

Are you, or have you been:

2.a

An investor of 10% or more in another SBIC?

2.b

An officer, director, member, manager or principal of an SBIC, a general partner of an SBIC, or the investment adviser/manager or an SBIC?

2.c

An employee of an SBIC, the general partner of an SBIC, or the investment adviser/manager of an SBIC?

2.d

A member of any investment committee or advisory committee of an SBIC?

If you answered “Yes” to any of the four questions above, please provide the name of the SBIC, your positions, and the dates of affiliation.

1

SBIC Fund I – Investment Committee Member – 4/08 to 5/12

2

SBIC Fund II – 10% or more Investor – 9/97 to 7/05

3

Are you a Close Relative (13 CFR 107.50) of any person Affiliated (13 CFR 121.103) with the Applicant or of any SBIC?

3.a

If “Yes”, provide the name of the SBIC and the relationship.

4

To the best of your knowledge and belief, during the past ten years, has any organization, either while you were a member of senior management or when you had a substantial direct or indirect ownership interest (20% or greater):

4.a

Borrowed funds from or sold securities to any Small Business Investment Company?

4.b

Received a loan from or guaranteed by the SBA (including, but not limited to, a Paycheck Protection Program "PPP" loan)?

4.c

If you answered “Yes” to either of the two questions above, please describe below, giving all pertinent details, including the names of all parties to the transaction, dates, amounts involved, terms, use of proceeds, etc., and the outcomes of the financings.

---

Sheet 3: Certification

Certification

As of Date:

MM/DD/YYYY

This declaration certification form is to be completed by each of the principals (as defined in the application instructions) and control persons (as defined in 13 CFR §107.50) of the applicant, signed with the submission of an SBIC MAQ, and resubmitted in the event of material changes at the time of final License Application. If any new principals or Control Persons are added to the firm after submitting the MAQ, a certification signed by the new principal or Control Person must be submitted to SBA. If a new principal or new Control Person is to be added to the SBIC after it is licensed, a certification signed by the new principal or Control Person must be submitted to SBA.

Name of Applicant:

ABC SBIC, L.P.

INSTRUCTIONS:

This form must be completed and signed by each principal of the SBIC entity and/or fund sponsor(s). PRIOR TO SIGNING THIS DOCUMENT, PLEASE READ THE “NOTICES REQUIRED BY LAW” TAB ON THIS EXHIBIT A FOR EXPLANATIONS ABOUT DISCLOSURE OF INFORMATION AND USES OF SUCH INFORMATION.

CERTIFICATION AND AUTHORIZATION TO RELEASE INFORMATION

I certify that all of the information I have provided on this Exhibit A and any other information I have submitted in connection with this Exhibit A is true, correct and complete to the best of my knowledge and there are no additional documents that would impact previously noted/listed executed documents. I understand that knowingly making a false statement is a violation of Federal law and could result in criminal prosecution under 18 USC §§ 287, 371, 1001, 1006, and 1014, including fines of up to $1 million and up to 30 years imprisonment, 15 USC §§ 645 and 687(f), civil penalties under 31 U.S.C. § 3729, government-wide debarment or suspension, and denial, suspension, or revocation of a Small Business Investment Company license. I have read the “Notices Required by Law” and I authorize the U.S. Small Business Administration Office of Inspector General to request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for the Small Business Investment Company program. In connection with an application for an SBIC license, or operation of an SBIC, I hereby authorize the U.S. Small Business Administration (“SBA”) and its agents to make inquiries, including obtaining a consumer report from a consumer reporting agency, to determine my personal credit standing.

Printed Name

Title

Signature

Date