Form SBA Form 860 SBA Form 860 Financial Institution Confirmation Form

OMB Approval No. 3245-0116

Expiration Date: xx/xx/xxxx

U.S. Small Business Administration

Investment Division ___________________, 20____

Dear Sir/Madam:

Your completion of the following report will be sincerely appreciated and response is strictly voluntary. If the answer to any item is "None," please so state. Please reply within ten (10) days. A self-addressed envelope is enclosed for your convenience.

Name of Bank Account Name per Bank Statement

Street Address Authorized Signature

City, State, Zip Code

Note: If space provided is inadequate, please enter totals

Examination Manager hereon and attach statement giving full details as called for

Office of SBIC Examinations by the column headings below.

1. At the close of business on _______________________, our records showed the following balance(s) to the credit of the above named customer. In the event that we could ascertain whether there were any balances to the credit of the customer not designated in this request, the appropriate information is given below.

Amount	Account Name	Account Number	Subject to withdrawal By check?	Interest bearing? Give Rate.
$

2. The customer was directly liable to us in respect of loans, acceptance, etc., at the close of business on that date in the total amount of $__________________, as follows:

Amount	Date of Loan or Discount	Due Date	Interest		Description of Liability, Collateral, Security Interests, Liens, Endorsers, etc.
			Rate	Paid to
$

3. The customer was contingently liable as endorser of notes discounted and/or as guarantor at the close of business on that date in the total amount of $______________________, as follows:

Amount	Name of Maker	Date of Note	Due Date	Remarks
$

4. Other direct or contingent liabilities, open letters of credit, and relative collateral, were:

5. Security agreements under the Uniform Commercial Code or any other agreements providing for restrictions, not noted above, were as follows (if officially recorded, indicate date and office in which filed):

Name

Title

Authorized Signature ___________________, 20____

Confidential information will be protected to the extent permitted by law.

PLEASE NOTE: The estimated burden for completing this form is 1/2 hour per response. You are not required to respond to any collection of information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to U.S. Small Business Administration, Chief, AIB, 409 3^rd St., S.W., Washington D.C. 20416 and Desk Officer for the Small Business Administration, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503 (OMB Approval 3245-0116). PLEASE DO NOT SEND FORMS TO OMB.

SBA Form 860 (11/09) Previous Editions Obsolete