Sba Form 159 Fee Disclosure Form And Compensation Agreement (Page 3 of 3) in pdf

Agent Name and Signature:

By ______________________________________

__________

(Signature of agent)

(Date)

_____________________________________________

(Name of agent – please print)

____________________________________________________________________

(Business name of agent – please print)

_____________________________________________________________________

(Business address of agent including zip code)

_____________________________________________________________________

(Business address cont.)

Applicant’s Certifications: The undersigned Applicant certifies to SBA that the above representations and amounts are

the only amounts paid (or that will be paid) by the Applicant in connection with the services covered by this form and are

satisfactory to the Applicant. The Applicant further certifies that a separate compensation agreement (SBA Form 159(7a))

False

has been executed for all Agents, as defined above, involved with this loan application. WARNING:

certifications can result in criminal prosecution under 18 U.S.C. § 1001 and other penalties provided

under law.

_______________________________________

By:________________________________________

_____________

(Applicant’s Name)

(Signature of authorized representative)

(Date)

___________________________________________

(Name of authorized representative – please print)

Lender’s Certifications: The undersigned 7(a) participating lender certifies that the representations of services rendered

and amounts charged as identified in this form are reasonable and satisfactory to it. The undersigned also certifies that he

or she has no knowledge that any other Agent, as defined above, was engaged by, represented or worked on behalf of the

Applicant other than as disclosed above or in another executed compensation agreement (SBA Form 159(7a)). The

undersigned further certifies that any referral fees described below are the only referral fees paid by the lender to a referral

agent in connection with this loan, and were not charged directly or indirectly to the Applicant. WARNING: False

certifications can result in criminal prosecution under 18 U.S.C. § 1001 and other penalties provided under law.

gggggggggggggggg

___________________________________

(Name of referral agent – please print)

______________________________________________

________________________________

(7(a) lender name)

Business name of agent – please print)

(

By:_________________________________ _________

________________________________________

(Signature of authorized lender representative)

(Date)

(Business address of agent including zip code)

___________________________________

________________________________________

(Name of authorized lender representative – please print)

(Business address cont.)

Referral fee paid, if any: $____________________

SBA Loan Number ___________________________________ (if approved)

SBA Form 159(7a) (8-14)

PLEASE NOTE: The estimated burden for completion of this Form 159 is 5 minutes per response. You are not required to respond to this

information collection unless it displays a currently valid OMB approval number. Comments or questions on the burden estimate should be sent to

U.S. Small Business Administration, Chief, Administrative Information Branch, Washington, D.C. 20416, and Desk Officer for SBA, Office of

Management and Budget, New Exec. Office Building, Room 10202, Washington, D. C. 20503. PLEASE DO NOT SEND FORMS TO THESE

ADDRESSES.

Sba Form 159 Fee Disclosure Form And Compensation Agreement Page 3

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