Sba Form 413 - Personal Financial Statement, Lisc Small Business Pre-Screen Form Page 2
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5LISC SMALL BUSINESS PRE-SCREEN FORM
6. Are you presently subject to an indictment, criminal information, arraignment, or other means by which formal criminal
charges are brought in any jurisdiction? ☐ YES ☐ NO
7. For any criminal offense – other than a minor vehicle violation – have you ever: 1) been convicted; 2) plead guilty; 3) plead
nolo contendere; 4) been placed on pretrial diversion; or 5) been placed on any form of parole or probation (including
probation before judgment)? ☐ YES ☐ NO
Business Experience
Do you have at least two years of direct experience in the industry in which you are requesting financing?
☐ YES ☐ NO
*After an initial review and completion of the intake process, you will be asked to provide a resume with proof of direct
industry experience.
Most recent employment experience:
Company Name:
Dates:
Address:
Position:
Responsibilities:
Use of Loan Proceeds
Amount
Building/Land Purchase $
Building Construction $
Leasehold Improvements $
Working Capital $
Inventory Purchase $
Equipment Purchase $
Business Acquisition $
Debt Refinance (please provide copies of notes) $
Fixed Start-Up Costs $
Other, please specify:
$
Total Project Cost (A): $
Borrower’s Injection/Down Payment (B):
$
Note: Borrowers are required to provide a down payment. Startups (companies in
business less than 2 years) must have a minimum down payment of 30% of total
project costs; business acquisitions require a 20% minimum down payment; established
businesses and real estate purchases require a 10% minimum down payment.
Total Loan Request (A-B):
$
Note: At this time, LISC provides loans between $50,000 and $250,000.
I authorize SBA/Lender to make inquiries as necessary to verify the accuracy of the statements made and to determine my
creditworthiness.
I hereby certify that: (1) as consideration for any Management, Technical, and Business Development Assistance that may be
provided, I waive all claims against SBA and its consultants, and (2) all information contained in this document and any attachments
is true and correct to the best of my knowledge.
Signature:
Date:
Print Name:
Title:
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