Sba Form 413 - Personal Financial Statement, Lisc Small Business Pre-Screen Form (Page 5 of 5) in pdf

Section 8. Life Insurance Held. (Give face amount and cash surrender value of policies – name of insurance company and

Beneficiaries.)

I authorize the SBA/Lender/Surety Company to make inquiries as necessary to verify the accuracy of the statements made and to

determine my creditworthiness.

CERTIFICATION: (to be completed by each person submitting the information requested on this form)

By signing this form, I certify under penalty of criminal prosecution that all information on this form and any additional supporting

information submitted with this form is true and complete to the best of my knowledge. I understand that SBA or its participating

Lenders or Certified Development Companies or Surety Companies will rely on this information when making decisions regarding an

application for a loan or a surety bond. I further certify that I have read the attached statements required by law and executive order.

Signature ________________________________________

Date

____________________

Print Name _______________________________________

Social Security No.

____________________

Signature ________________________________________

Date

____________________

Print Name _______________________________________

Social Security No.

____________________

NOTICE TO LOAN AND SURETY BOND APPLICANTS: CRIMINAL PENALITIES AND ADMINISTRATIVE REMEDIES FOR

FALSE STATEMENTS:

Knowingly making a false statement on this form is a violation of Federal law and could result in criminal prosecution, significant civil

penalties, and a denial of your loan or surety bond application. A false statement is punishable under 18 U.S.C. §§ 1001 and 3571 by

imprisonment of not more than five years and/or a fine of up to $250,000; under 15 U.S.C. § 645 by imprisonment of not more than

two years and/or a fine of not more than $5,000; and, if submitted to a Federally-insured institution, a false statement is punishable

under 18 U.S.C. § 1014 by imprisonment of not more than thirty years and/or a fine of not more than $1,000,000. Additionally, false

statements can lead to treble damages and civil penalties under the False Claims Act, 31 U.S.C. § 3729, and other administrative

remedies including suspension and debarment.

PLEASE NOTE:

The estimated average burden hours for the completion of this form is 1.5 hours per response. If you have questions or comments concerning this estimate or any other aspect of this

information, please contact Chief, Administrative Branch, U.S. Small Business Administration, Washington, D.C. 20416, and Clearance officer, paper Reduction Project (3245-0188), Office

of Management and Budget, Washington, D.C. 20503. PLEASE DO NOT SEND FORMS TO OMB.

SBA Form 413 (7a/504/SBG) (09-14) Previous Editions Obsolete

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