Form Sba 912 (5-97) - Statement Of Personal History Form

OMB APPROVAL NO.3245-0178

Return Executed Copies 1, 2, and 3 to SBA

Expiration Date:7/31/2000

Please Read Carefully - Print or Type

Each member of the small business concern or the development company requesting

United States of America

assistance must submit this form in TRIPLICATE for filing with the SBA application. This

form must be filled out and submitted by:

SMALL BUSINESS ADMINISTRATION

1.

If a sole proprietorship by the proprietor.

2.

If a partnership by each partner.

STATEMENT OF PERSONAL HISTORY

3.

If a corporation or a development company, by each officer, director, and additionally by

each holder of 20% or more of the voting stock.

4.

Any other person including a hired manager, who has authority to speak for and commit

the borrower in the management of the business.

Name and Address of Applicant (Firm Name)(Street, City, State, and ZIP Code)

SBA District/Disaster Area Office

Amount Applied for (when applicable)

File No. (if known)

1. Personal Statement of: (State name in full, if no middle name, state (NMN), or if initial

Name and Address of participating lender or surety co. (when applicable and known)

only, indicate initial.) List all former names used, and dates each name was used.

Use separate sheet if necessary.

First

Middle

Last

2. Date of Birth (Month, day, and year)

3. Place of Birth: (City & State or Foreign Country)

4. Give the percentage of ownership or stock owned or

Social Security No.

U.S. Citizen?

YES

NO

to be owned in the small business concern or the

Development Company

If no, give alien registration number:

5.

Present residence address:

Most recent prior address (omit if over 10 years ago):

From:

From:

To:

To:

Address:

Address:

Home Telephone No. (Include A/C):

Business Telephone No. (Include A/C):

IT IS AGAINST SBA'S POLICY TO PROVIDE ASSISTANCE TO PERSONS NOT OF GOOD CHARACTER; THEREFORE, CONSIDERATION IS GIVEN TO A

PERSON'S BEHAVIOR, INTEGRITY, CANDOR, AND DISPOSITION TOWARD CRIMINAL ACTIONS. IT IS ALSO AGAINST SBA'S POLICY TO PROVIDE

ASSISTANCE NOT IN THE BEST INTEREST OF THE UNITED STATES; FOR EXAMPLE, IF THERE IS REASON TO BELIEVE THE EFFECT OF SUCH

ASSISTANCE WILL BE TO ENCOURAGE OR SUPPORT, DIRECTLY OR INDIRECTLY, ACTIVITIES HARMFUL TO THE SECURITY OF THE UNITED

STATES.

THEREFORE, IT IS IMPORTANT THAT THE NEXT THREE QUESTIONS BE ANSWERED TRUTHFULLY AND COMPLETELY. AN ARREST OR

CONVICTION RECORD WILL NOT NECESSARILY DISQUALIFY YOU; HOWEVER, AN UNTRUTHFUL ANSWER WILL CAUSE YOUR APPLICATION TO BE

DENIED.

IF YOU ANSWER "YES" TO 6, 7, OR 8, FURNISH DETAILS IN A SEPARATE EXHIBIT. INCLUDE DATES, LOCATION, FINES, SENTENCES, WHETHER

MISDEMEANOR OR FELONY, DATES OF PAROLE/PROBATION, UNPAID FINES OR PENALTIES, NAME(S) UNDER WHICH CHARGED, AND ANY OTHER

PERTINENT INFORMATION.

6. Are you presently under indictment, on parole or probation?

Yes

No

(If yes, indicate date parole or probation is to expire.)

7. Have you ever been charged with and or arrested for any criminal offense other than a minor motor vehicle violation? Include offenses which have been dismissed, discharged, or

not prosecuted (All arrests and charges must be disclosed and explained on an attached sheet.)

Yes

No

8. Have you ever been convicted, placed on pretrial diversion, or placed on any form of probation, including adjudication withheld pending probation, for any criminal offense other than

a minor vehicle violation?

Yes

No

9. I authorize the 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 programs authorized by the Small Business Act, as amended.

CAUTION: 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,

surety bond, or other program participation. A false statement is punishable under 18 USC 1001 by imprisonment of not more than five years and/or a fine of not more than $10,000;

under 15 USC 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, under 18 USC 1014 by

imprisonment of not more than twenty years and/or a fine of not more than $1,000,000.

Signature

Title

Date

Agency Use Only

10.

11.

Fingerprints Waived

Cleared for Processing

Date

Approving Authority

Date

Approving Authority

Fingerprints Required

Request a Character Evaluation

Date

Approving Authority

Date

Approving Authority

Date Sent to OIG

Please Note: The estimated burden for completing this form is 15 minutes per response. You will not be required to respond to this information if a valid OMB approval number

is not displayed. If you have questions or comments concerning this estimate or other aspects of this information collection, please contact the U.S. Small Business

Administration, Chief, Administrative Information Branch, Washington, D.C. 20416 and/or Office of Management and Budget, Clearance Officer, Paperwork Reduction Project.

SBA 912 (5-97) SOP 5010.4 Previous Edition Obsolete

This form was electronically produced by Elite Federal Forms, Inc.