SBA Form 770 FINANCIAL STATEMENT OF DEBTOR

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.

5. SOCIAL SEC. NO.

6. OCCUPATION

7. HOW LONG IN PRESENT EMPLOYMENT?

8. EMPLOYER’S NAME

ADDRESS (Include ZIP Code)

PHONE NUMBER

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

10. OTHER EMPLOYERS Name

WITHI

N LAST

3

YEARS 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)

ADDRESS (Include ZIP Code)

PHONE NUMBER

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

$ $ $ $

17. OTHER EMPLOYERS WITHIN LAST 3 YEARS (Of Spouse) Name Address Dates of Employment

18. OTHER DEPENDENTS: NUMBER Name Relationship Age

23. FIXED MONTHLY EXPENSES: (TO NEAREST DOLLAR) Rent or House Payment $ Utilities $ Food $ Interest $ Insurance $ Debt Repayments: Household furnishings $ Personal Loans $ Automobile $ Doctors and Dentist $ Other (Specify) $

19. TOTAL MONTHLY INCOME OF DEPENDENTS (Except Spouse) $

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

21. WHERE WAS TAX RETURN FILED?

22. AMOUNT OF GROSS INCOME REPORTED $

TOTAL FIXED MONTHLY EXPENSES $

24. ASSETS AND LIABILITIES (SHOW AMOUNTS TO THE NEAREST DOLLAR)
ASSETS: (Fair Market Value)					LIABILITIES
Cash			$		Bills owed (grocery, doctor, lawyer, etc.)			$
Checking Accounts: (Show location)					Installment debt (car, furniture, clothing, etc.)			$
			$		Taxes Owed:
			$		Income			$
Savings Accounts: (Show location)					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?)
			$					$
			$					$
Debts owed to you: (Name of debtor)					Small Business Administration			$
			$		Loans of Life Insurance			$
			$		Mortgages of Real Estate
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			$
			$
TOTAL ASSETS:			$		CONTINGENT LIABILITIES			$
25. LOANS PAYABLE
Owed To:	Date of Loan	Original Amount			Present Balance	Terms of Repayments	How Secured?
		$			$	$
		$			$	$
		$			$	$
26. REAL ESTATE OWNED (Free & Clear): Address				How Owned (Jointly, individually, etc.)		Present Market Value
						$
						$

27. REAL ESTATE BEING PURCHASED ON CONTRACT OR MORTGAGE (Address)	Date Acquired					Balance Owed: $
	Name of Seller or Mortgagor
	Purchase Price $					Date Next Cash Payment Due
	Present Market Value $					Amount of Next Cash Payment $
28. LIFE INSURANCE POLICIES: Company			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 LAWSUIT 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? YES NO IF YES, GIVE DETAILS
34. WHEN DO YOU BELIEVE THAT YOU CAN START MAKING PAYMENTS ON YOUR SBA DEBT?				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 (xx-xx) REF SOP 50-57 and 50-52 Previous Editions Obsolete

Privacy Act Statement: 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 as amended on March 16, 2012, at 77 FR 15830 and as amended on October 9, 2012 at 77 FR 61467 and Federal Register / Vol. 86, No. 82 / Friday, April 30, 2021 / Notices., SBA 20, Disaster Loan Case File published on April 1, 2009, at 74 FR 14890 and updated on November 18, 2021,Federal Register / Vol. 86, No. 2. 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, 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] and the Covid EIDL Servicing Center, 14925 Kingsport Road, Fort Worth, TX 76155, fax 202-481-5799, 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 Business Administration, Director, Records Management Division, 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, DC 20503. OMB Approval (3245-0012). PLEASE DO NOT SEND FORMS TO OMB.

NOTE: USE ADDITIONAL SHEETS WHERE SPACE ON THIS FORM IS INSUFFICENT PAGE 4

SBA Form 770 (xx-xx) REF SOP 50-57 and 50-52 Previous Editions Obsolete

NOTE: USE ADDITIONAL SHEETS WHERE SPACE ON THIS FORM IS INSUFFICENT

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SBA Form 770 (xx-xx ) REF SOP 50-57 and 50-52 Previous Editions Obsolete