Sba Form 1081 - Statement Of Personal History (For Use By Lenders)
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4OMB APPROVAL NO.: 3245-0080
EXPIRATION DATE: 12-31-2019
Please Read Carefully and Fully Complete: SBA uses the Form
U.S. Small Business Administration
1081 to determine the eligibility of an individual to participate in
SBA Loan Programs. Please reference SBA Regulations and
Standard Operating Procedures if you have any questions about
STATEMENT OF PERSONAL HISTORY
who must submit this form and where to submit it. Do not send
completed forms to OMB as that will delay the processing of
your application; send forms to SBA.
(FOR USE BY LENDERS)
Lender Name
Lender Address (Street, City, State, Zip Code ) and Email Address
1. First Name
Middle Name (if none, so state)
Last Name
Date of Birth
3. Place of Birth (City and State or Foreign Country)
2.
(month, day & year)
4. U.S. Citizen?
Yes
No
INITIALS:
____
5. Social Security Number:
If no, are you a Lawful Permanent Resident Alien?
Yes
No Alien Registration Number:
If no, Country of Citizenship:
6. Starting with present address, attach a list of residence addresses for the last ten years using the following format:
Address
From (Date)
To (Date)
7. Employment, Professional History and Education: Attach a resume that provides a summary of: (a) your business or
professional experience during the last ten years up to and including the present, stating the periods of each primary
activity; the names, addresses and nature of business of the concerns with which you associated; title and position in
such concerns; and your basic functions and responsibilities in such concerns; (b) a summary of your education
showing highest level attained (such as high school graduate, bachelor's degree, master's degree, etc., and giving,
when applicable, the name of the higher educational institution, your specialization, and date of degree); (c) a
summary of any special experience or qualifications pertinent to your responsibilities in connection with the management
or operation of all lender and (d) identify and relate your business and professional experience during the past ten
years to your qualifications to direct the management, policies or operations of an SBA Lender or SBA Microloan
Intermediary (as defined in 13 CFR 120.10).
Present Affiliations and/or Associations: Attach a list of all business concerns or entities with which you are presently
8.
Affiliated. (as defined in 13 CFR §121.103), and/or Associated (as defined in 13 CFR §120.10), or in which you have
.
direct or indirect ownership or control of 10% or more of any class of stock or proprietary interest
Include the names,
addresses, and nature of business of such concerns or entities, and provide the details of your relationships and
ownership, including the percentage ownership of any stock, equity, voting, profit or proprietary interest owned.
Page 1 of 4
SBA Form 1081 (9-16) Previous Edition is Obsolete
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