Personal Financial Statement - Women Owned Small Business (Wosb) Program (Page 3 of 4) 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 to make inquiries as necessary to verify the accuracy of the statements made and to determine my economic

status.

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 will rely on this

information when making decisions regarding eligibility for SBA’s Women-Owned Small Business Program. I further certify that I

have read the attached statements required by law and executive order.

Signature ________________________________________

Date

____________________

Print Name _______________________________________

NOTICE TO BUSINESSES IN THE WOSB PROGRAM:

CRIMINAL PENALITIES AND ADMINISTRATIVE REMEDIES FOR FALSE STATEMENTS:

Any person who misrepresents a business concern’s status as a WOSB or EDWOSB, or makes any other false statement in order to

influence the WOSB Program eligibility determination or other review process in any way (e.g., protest), shall be: (1) subject to fines

and imprisonment of up to 5 years, or both, as stated in Title 18 U.S.C. § 1001; (2) subject to fines of up to $500,000 or imprisonment

of up to 10 years, or both, as stated in Title 15 U.S.C. § 645; (3) subject to civil and administrative remedies, including suspension and

debarment; and (4) ineligible for participation in programs conducted under the authority of the Small Business Act.

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 (WOSB) (09-14) Previous Editions Obsolete

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