Sba Form 1031 - Portfolio Financing Report - U.s. Small Business Administration
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2OMB No. 3245-0078
Expiration Date 10/31/2017
U.S. Small Business Administration
Portfolio Financing Report
Name of Licensee___________________________________
License Number___________
Part A - Small Business Concern Data
1. Name of Small Business ___________________________________
2. Employer Identification Number ____-____________
3. Street Address _________________________________________________________________________________
4. City_________________________ 5. State______ 6. ZIP Code _________ 7. County __________________________
8. Small Business FAX __________________________ 9. Contact Person for FAX _______________________________
10. Date Business Established __/__/__ 11. Form of Business ____ 1) Corporation 2) Partnership 3) Proprietor 4) LLC
12a. NAICS Code ______________ Industry __________________________________________
12b. Energy Saving Qualified Investment? ____ If checked, was Energy Saving debenture used to finance investment? _____
13. Percentage of Small Concern (if any) Owned by:
American Indian or Alaska Native: ____%
Asian: ____%
Black or African American: ____% Hispanic or Latino: ____% Native Hawaiian or Other Pacific Islander: ____% White: ____%
14a. Percentage of Small Concern Owned by Women (if any) _____% 14b. Percentage Owned by Veterans (if any) _______%
15. CEO or President (may select one or more):
Woman:____
American Indian or Alaska Native: ____
Asian: ____
Black or African American: ____ Hispanic or Latino: ____ Native Hawaiian or Other Pacific Islander: ____ White: ____
Part B - Prefinancing Information
16. Prefinancing Status: ____ (1) New Information (2) Previously Submitted (3) Acquired Business (4) New Business
17a. Stage of Company at Financing:________________ 17b. Technology developed with SBIR/STTR funding:_____________
18. Small Business Concern’s Pre-Money Valuation: ___________________________
19. Fiscal Year End Immediately Prior to Date of Financing (Month/Day/Year) _____/_____/_____
20. Gross Revenue for Prior Fiscal Year $______________
21. After-Tax Profit or (Loss) for Prior Fiscal Year $____________
22. Income Taxes for Prior Fiscal Year: Federal $_________________ State $_________________ Local $________________
23. Net Worth $______________
24. Number of Employees _________
Part C - Financing Information
25. a. Date of Financing ___/___/____
b. Date of Disbursement ___/___/____
26. Did Licensee lead this investment? _____
27. Purpose of Financing
(Percentage of Financing that will be used to support each category below. Percentages should total to 100%.)
____
____
a. Working Capital or Inventory Purchase
f. Acquisition of Machinery and Equipment
____
____
b. Plant Modernization or Leasehold Improvement
g. Land Acquisition or Dwelling Construction
____
____
c. Acquisition of All or Part of an Existing Business
h. Marketing Activities
____
____
d. Consolidation of Obligations or Non-SBIC Debt Refunding
i. Research and Development
____
____
e. New Building or Plant Construction
j. Other
28. Is this the first Financing of this Small Business by the Licensee? _______
29. Financing Instruments and Applicable Amounts (for participations, include Licensee's portion only):
Instrument
Amount
Initial Interest Rate(s)
% Actual Ownership
Loan Only
$__________
__________%
Debt with Equity Features
$__________
__________%
Equity Only
$__________
__________%
Total Licensee Financing
$__________
30. Total Size of Financing Round for Small Business Concern: _________________________
31. Comments:
Transmission Date _____/_____/_____
Part D - Transmission Verification
SBA Form 1031 (3/14) Previous Editions Obsolete
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Parent category: Financial