Sba 1031 Portfolio Financing Report

U.S. Small Business Administration

OMB No. 3245-0078
Exp. Date 12/31/2010

Portfolio Financing Report

Name of Licensee

License Number

Part A - Small Business Concern Data
1.
3.
4.

Name of Small Concern
Street Address
City

8.

Small Business FAX

2. Employer Identification Number
5. State

6. Zip Code
9. Contact Person for FAX
11. Form of Business

10. Date Business Established
12. NAICS Code

Industry

13. Percentage of Small Concern (if any) Owned by:
Black or African American:

%

American Indian or Alaska Native:

Hispanic or Latino:

%

14. Percentage of Small Concern Owned by a) Women (if any)
15a. CEO or President:

7. County

%

Native Hawaiian or Other Pacific Islander:
%

b) Veterans (if any)

Asian:
% White:

%

Woman:

15b. CEO or President (may select one or more)
Black or African American:

American Indian or Alaska Native:

Hispanic or Latino:

Asian:

Native Hawaiian or Other Pacific Islander:

White:

Part B - Prefinancing Information
16. Prefinancing Status

17. Stage of Company at Financing:

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 (Loss) for Prior Fiscal Year

22. Income Taxes for Prior Fiscal Year: Federal
23. Net Worth

State

Local

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
b. Plant Modernization or Leasehold Improvement
c. Acquisition of All or Part of an Existing Business
d. Consolidation of Obligations or Non-SBIC Debt Refunding
e. New Building or Plant Construction

f. Acquisition of Machinery and Equipment
g. Land Acquisition or Construction on Existing Land
h. Marketing Activities
i. Research and Development
j. Other

28 Is this the First Financing of this Small Business by the Licensee?
29. Financin g instruments and A pp licable Amounts (fo rpartici pations , include Licensee's portion onl y):
Amount
Initial Interest Rate (s)
% Actual Ownership
Instrument
Loan Only
Debt with Equity Features
Equity Only
Total Licensee Financing

%
%
%

30. Total Size of Financing Round for Small Business Concern:
31. Comments
Part D - Transmission Verification

SBA Form 1031 (06/07) Previous Editions Obsolete

Transmission Date

%
%

SBA Form 1031

U.S. Small Business Administration
Portfolio Financing Report

OMB No. 3245-0078
Expiration Date 12/31/2010

If you have leverage or a leverage commitment, file Form 1031A (Portfolio Financing Report Certification) semiannually with your semi-annual valuation
report and your year-end Form 468 (Annual Financial Report). If you do not have leverage or a leverage commitment, file Form 1031A annually with your
Form 468.
PLEASE NOTE: The estimated burden for completing this form is 12 minutes per response. You will not be required to respond to this information collection
if a valid OMB approval number is not displayed. If you have questions or comments concerning this estimate or other aspects of this information collection,
please contact the U.S. Small Business Administration, Chief, Administrative Information Branch, Washington, DC 20416 and/or office of Management and
Budget, Clearance Officer, Paperwork Reduction Project (3245-0078), Washington, DC 20503. PLEASE DO NOT SEND FORMS TO OMB.

SBA Form 1031 (06/07) Previous Editions Obsolete