SBA Form 468.4 Corporate SBIC'S SORT FORM

SBAFORM 468

OMB Approval No. 3245-0063

(Corporate SBICs)

Expiration Date mm/dd/yyyy

SHORT FORM

Name of Licensee:
License Number:
Street Address:
City, State, and Zip Code:
County:
Employer ID Number:
For the Reporting Period Ending:

Months:

A- Fund Focus
B- Ownership

SBA Form 468 is to be completed only by small business investment companies (SBICs) licensed by the Small
Business Administration. This form contains financial statements and supplementary information which SBA
uses to evaluate an SBIC's financial condition and compliance with its business plan and SBIC program requirements.
SBA also pools financial information provided by individual SBICs to analyze the SBIC program as a whole with
respect to the risk of financial loss to the government and the impact of SBIC financings on the growth of small
business.
Form 468 must be completed and filed electronically in the SBIC-Web system. Within the system, you may also
upload supplemental documents as the form instructs.
SBIC-Web requires an SBA-approved user account. Submit your account request to sbicwebsupport@sba.gov.

Please Note: The estimated burden for completing this form is 23 hours 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, D.C. 20416
and/or SBA Desk Officer, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503. PLEASE DO

NOT SEND FORMS TO OMB.

SBA Form 468.4 (02/14) Previous edition obsolete .

Page lC

STATEMENT OF FINANCIAL POSITION
ASOF __________________

OMB Approval No. 3245-0063
Expiration Date mm/dd/yyyy

(Amounts rounded to nearest dollar)
Name of Licensee:

ASSETS

License No.

-·

LOANS AND INVESTMENTS:

Unrealized

Unrealized

Reported

Cost

Depreciation

Appreciation

Value (1)

(Col. 1)

(Col. 2)

(Col. 3)

(Col. 4)

Portfolio Securities:
1 Loans
2 Debt Securities
3 Equity Securities
4 Total Portfolio Securities
Assets Acquired in Liquidation of Portfolio Se.;:.
cu
: :r:..:.it::.ie
: :s:.:.:_ _ _ _-r---------,r---------.---------,
5 Receivables from Sale of Assets Acquired
6 Assets Acquired
7 Total Assets Acquired

1--------1----------11-------+---------1

8 Operating Concerns Acquired
9 Notes and Other Securities Received

10 TOTAL LOANS AND INVESTMENTS
11 Less Current Maturities
12 Loans and Investments Net of Current Maturities
Investment in 301(d) Lric:....:e..n.:..
:. .: se:...:e:...:(!...2..:). . - - - - - - - - - - - - ,
13 Name/License No.

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CURRENT ASSETS
14 Cash and Cash Equiv aIents
15 Invested Idle Funds
16 Interest and Dividen ds Receivable
17 Notes and Accounts Receivable
18 Receivables from Pa rent or Other Associates
19 Less: Allowance for Losses (lines 16, 17, and 18)
20 Current Maturities of Portfolio Securities
21 Current Maturities of Assets Acquired
22 Current Maturities o f Operating Concerns Acquired
23 Current Maturities of Other Securities
24 Other (specify)

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25 Other (specify)

OTHER ASSETS
26 Net Furniture and Equipment
27 Net Leverage Fees
28 Other (specify)
29 Other (specify)

30 TOTAL ASSETS
(1) Column Headings apply to items 1 through 12 only. (Cost- Unrealized Depreciation+ Unrealized Appreciation= Value)
(2) Note to item 13 should include percent owned, cost basis and changes resulting from equity method of accounting.

SBA Form 468.4 (02/14) Previous edition obsolete .

Page 2C

STATEMENT OF FINANCIAL POSITION
ASOF

---------------------(Amounts rounded to nearest dollar)

Name of Licensee :

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LIABILITIES AND CAPITAL

-

OMB Approval No. 3245-0063
Expiration Date mm/dd/yyyy

License No.
~··

Liabilities
Long-Term Debt
31 Notes and Debentures payable to or guaranteed by SBA
32 Notes and Debentures Payable to Others
33 a. 4% Redeemable Preferred Stock (30l(d) Licenses Only)
b. Cumulative Undeclared 4% Dividends

Current Liabilities
34 Accounts Payable
35 Due to Parent or Other Associates
a. Management Ex penses Due to Associates
b. Other Due to Ass ociates
36. Accrued Interest Pa yable
37. Accrued Taxes Paya ble
38. Dividends Payable
39. Short-term notes Pa yable/Lines of Credit

40 Other (specify)
41 Other (specify)

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Other Liabilities
42 Deferred Credits
43 Deferred Fee Income

44 Other (specify)

.-------------------------~

45 Total Liabilities
CAPITAL
46 Capital Stock
47 Paid-in Surplus
48 Restricted Contributed Capital Surplus
49 Capital Stock and Surplus
50 3% Preferred Stock Purchased by SBA
51 Unrealized Gains (Loss) on Securities Held
52 Non-Cash Gains/Income
53 Undistributed Net Realized Earnings
a. Restricted (Equal to Cost ofTreasury Stock)
b. Unrestricted
c. Total (53a plus 53b)
54 Undistributed Realized Earnings (line 52 plus line 53c)

55 Total
56: Less: Cost of Treasury Stock

57 TOTAL CAPITAL
58 TOTAL LIABILITIES AND CAPITAL (LINES 45 AND 57)
SBA Form 468.4 (02/14) Previous edition obsolete.

Page 3C

STATEMENT OF OPERATIONS REALIZED
For
MONTHS ENDED _ _ __

OMB Approval No. 3245-0063
Expiration Date mm/dd/yyyy

{Amounts rounded to nearest dollar)
Name of Licensee :

I

License No.

INVESTMENT INCOME
!Interest Income
2 Dividend Income
3 Income {Loss) from Investments in Partnerships/Flow-through Entities
4 Income (Loss) from Investments in Section 301(d) Licensee
5 Fees for Management Services
6 Application, Closing and Other Fees
7 Interest on Cash Equivalents and Invested Idle Funds
8 Income from Assets Acquired in Liquidation of
Loans and Investment (net of$ _ _ _ _ _ Expenses)
9 Other Income

10 GROSS INVESTMENT INCOME
EXPENSES
lllnterest Expense
a. Interest Expense-- SBA Debentures
b. Other Interest Expense

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12 Commitment Fees & Other Financial Costs
13 Compensation and Benefits (Officer and Employee)
14 Investment Advisory and Management Services
15 Director's and Stockholder's Meetings
16 Appraisal and Investigation
17 Advertising, Communication and Travel
18 Cost of Space Occupied
19 Depreciation and Amortization
a. Amortization of Leverage Fees
b. Other Depreciation and Amortization

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20 I nsu ranee
21 Payroll and Other Taxes
22 Provision for Losses on Receivables (excluding loans receivable)
23 Legal Fees
24 Audit and Examination Fees
25 Miscellaneor-us:...E:...x.:::p..:e:...ns:..:e:..:.s_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____,
a. Misc. #1
b. Misc. #2
c. Misc. #3
d. Misc. #4
e. Misc. #5
f . Misc. #6

26 TOTAL EXPENSES
27 NET INVESTMENT INCOME (LOSS)
28 NET REALIZED GAIN (LOSS) ON INVESTMENTS (1)
29 NET INCOME (LOSS) BEFORE NONRECURRING ITEMS
30 Extraordinary Item
31 Cumulative Effect of Change in Accounting Principle

32 NET INCOME (LOSS)
{1) Provide supporting detail for all realized gains and losses on Page 13C of this form .

SBA Form 468.4 (02/14) Previous edition obsolete .

Page 4C

STATEMENT OF CASH FLOWS
MONTHS ENDED _ _ __
For

OMB Approval No. 3245-0063
Expiration Date mm/dd/yyyy

(page 1 of 2)
(Amounts rounded to nearest dollar)
License No .

Name of Licensee :

OPERATING ACTIVITIES
Cash Inflows
!Interest Received from Portfolio Concerns
2 Dividend Received from Portfolio Concerns
3 Other Income Received from Portfolio Concerns
4 Management Services and Other Fees Received
5 Interest on Cash Equivalents and Invested Idle Funds
6 Cash Received from Assets Acquired in Liquidations
7 Other Operating Cash Receipts
Cash Outflows
8 Interest Paid
9 Commitment Fees and Other Financial Costs
10 Investment Advisory and Management Fees
11 Officers, Directors and Employees' Compensation and Benefits
12 Operating Expenditures (Excluding Compensation and Benefits)
13 Income Taxes paid
14 Other Operating Cash Disbursements
15 NET CASH PROVIDED BY {USED IN) OPERATING ACTIVITIES

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INVESTING ACTIVITIES
Cash Inflows
16 Loan Principal Payments Received from Portfolio Concerns
17 Returns of Capital Received from Portfolio Concerns
18 Net Proceeds from Disposition of Portfolio Securities
19 Liquidation of Idle Funds Investments
~~~~~~~------------------------~
20 Other (Specify)
Cash Outflows
21 Purchase of Portfolio Securities
22. Loans to Portfolio concerns
23 Idle Funds Investment
24 Other (Specify)
25 NET CASH PROVIDED BY (USED IN) INVESTING ACTIVITIES

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FINANCING ACTIVITIES
Cash Inflows
26 Proceeds from Issuance of SBA-Guaranteed Debentures
27 Proceeds from Non-SBA Borrowing
28 Proceeds from Sale of Stock or Other Capital Contribution
29 Other (Specify)
Cash Outflows
30 SBA Leverage Fees
31 Principal Payments on SBA-Guaranteed Debentures
32 Principal Payments on Non-SBA Borrowing
33 Redemption of 4% Preferred Stock
34 Redemption of 3% Preferred Stock
35 Redemption of Stock (excluding 3% and 4% Preferred)
36 Dividends Paid
37 Other (Specify)
38 NET CASH PROVIDED BY {USED IN) FINANCING ACTIVITIES

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r--------------------------------------,

SBA Form 468.4 (02/14) Previous edition obsolete.

Page SC

OMB Approval No. 3245-0063

STATEMENT OF CASH FLOWS
For

MONTHS ENDED----

Expiration Date mm/dd/yyyy

(page 2 of 2)
(Amounts rounded to nearest dollar)

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Name of Licensee :

J

License No.

39 INCREASE (DECREASE) IN CASH AND CASH EQUIVALENTS
40 CASH AND CASH EQUALENTS AT BEGINNING OF PERIOD
41 CASH AND CASH EQUIVALENTS AT END OF PERIOD (line 14, page 2C)

RECONCILIATION OF NET INCOME (LOSS) TO NET CASH PROVIDED BY (USED IN) OPERATING ACTIVITIES

~.:-'-=--------'

42 Net Income (Loss) (Line 32, page 4C)

Adjustments to Reconcile Net Income (Loss) to Net Cash Provided by (used in) Operating Activ_rit.;;;.ie
..;;.;s;.;.:_ _ _
1
43 Depreciation and Amortization (line 19, page 4C)
44 Provision for Losses on Accounts Receivable (line 22, page 4C)
45 Provision for Deferred Income Taxes
46 Realized (Gains) Losses on Investments (line 28, page 4C)

47 Other

(S::_pe:_:c_ify:_:)_.:::===========:;----~

~:~-----1

- - -

§

Changes in Operating Assets and Liabilities Net of Noncash Items
48 (Increase) Decrease in Interest and Dividends Receivable
49 (Increase) Decrease in Other Current Assets
50 Increase (Decrease) in Accounts Payable
51 Increase (Decrease) in Accrued Interest Payable
52 Increase (Decrease) in Accrued Taxes Payable
53 Increase (Decrease) in Dividends Payable
54 Increase (Decrease) in Other Current Liabilities
55 Other (Specify)
56 Other (Specify)

57 NET CASH PROVIDED BY (USED IN) OPERATING ACTIVITIES
(Total must agree with line 15, page SC)

Supplemental disclsure of non-cash financing and investing activites may be required .
See ASC 230, "Statement of Cash Flows ."

SBA Form 468.4 (02/14) Previous edition obsolete.

Page 6C

STATEMENT OF STOCKHOLDER'S EQUITY

OMB Approval No. 3245-0063
Expiration Date mm/dd/yyyy

ASOF -------------(page 1 of 2)
(Amounts rounded to nearest dollar)
Name of Licensee :

I

License No.
CAPITAL

PART I. CAPITAL STOCK AND PAID-IN SURPLUS

PAID-IN SURPLUS

TOTAL

NON-CASH
GAINS/INCOME

UNDISTRIBUTED NET
REALIZED EARNINGS

UNDISTRIBUTED
REALIZED EARNINGS

(1)

(2)

(1) + (2)

STOCK
(page 3P, line 46a)

1 BALANCE AT BEGINNING OF PERIOD
2 ADDITIONS:
a. Capital stock issued for cash
b. Capital stock issued for services rendered
c. Capital stock issued for contributed non-cash assets
d. Capitalization of Retained Earnings Available for Distribution
e. Gain on Sale of Treasury Stock
f. Other credits (specify) _ _ _ _ _ _ _ _ _ _ _ __
3 Total additions (sum of 2a through 2f)
4 Subtotal (line 1 plus line 3)
S DEDUCTIONS:
a. Retirement of capital stock
b. Return of capital distributions
c. Loss on sale of Treasury Stock
d. Other debits (specify) _ _ _ _ _ _ _ _ _ _ _ __
6 Total deductions (sum of Sa through Sd)
7 BALANCE AT END OF PERIOD (line 4 minus line 6)-Total must agree with lines 46 and 47, page 3C

PART II. UNDISTRIBUTED REALIZED EARNINGS
1 BALANCE AT BEGINNING OF PERIOD
2 ADDITIONS:
a. Net investment income
b. Realized gain (loss) on investments
c. Gain on appreciation of securities distributed in kind
d. Other (specify) - - - - - - - - - - - - - - - - - - - - - 3 Total additions (sum of 2a through 2d)
4 Subtotal (line 1 plus line 3)
S DEDUCTIONS:
a. Dividends- Cash
b. Dividends -Stock
c. Dividends- In-Kind (at fair value)
d. Capitalization of Retained Earnings available for Distribution
e. Other (specify) _ _ _ _ _ _ _ _ _ _ __
6 Total deductions (sum of Sa through Se)
7 Total before collection of non-cash gains/income
(line 4 minus line 6)
8 Collection of non-cash gains/income

9 BALANCE AT END OF PERIOD (line 7 plus line 8)Totals must agree with lines 52, 53c and 54, page 3C

SBA Form 468.4 (02/14) Previous edition obsolete.

Page 7C

I. RETAINED EARNINGS AVAILABLE FOR DISTRIBUTION
II. REGULATORY AND LEVERAGEABLE CAPITAL

OMB Approval No. 3245-0063
Expiration Date mm/dd/yyyy

ASOF -------------(Amounts rounded to nearest dollar)
Name of Licensee :

I

License No.

PART I. RETAINED EARNINGS AVAILABLE FOR DISTRIBUTION OR CAPITALIZATION.
1 Undistributed net Realized Earnings (line 53b, page 3C)
2 LESS: Unrealized Depreciation (line 10, column 2, page 2C)
3 ADD : Cumulative Unpaid distributions on 4% Redeemable
Preferred Stock--Section 301(d) Licensees only (line 33b, page 3C)
4 RETAINED EARNINGS AVAILABLE FOR DISTRIBUTION OR CAPITALIZATION

PART II. SCHEDULE OF REGULATORY AND LEVERAGEABLE CAPITAL
1 Capital Stock and Paid-in Surplus (sum of lines 46 and 47, page 3C)
2 ADD : Unfunded binding commitments from Institutional Investors
3 LESS : Regulatory Distributions
a. Organization Expenses Not Approved by SBA (1)
b. Capital Stock Issued for Services
c. Capital Stock Issued for Non-cash Assets (unless approved by
SBA for inclusion in Regulatory Capital or converted to cash)
d. Treasury Stock at Cost
e. Other (specify) _ _ _ _ _ _ _ _ _ _ _ __
4 Total Regulatory Deductions (Sum of 3a through 3e)
5 Other Adjustments to Regulatory Capital (specify) _ _ _ _ _ _ _ _ _ _ _ __

6 REGULATORY CAPITAL (sum of lines 1, 2, 4, and 5)
7 LESS : Unfunded binding commitments from Institutional Investors

8 LESS : Non-cash assets included in Regulatory Capital, other than eligible investments in Small Concerns
9 LESS : Other deductions (specify) - - - - - - - - - - - - - - - - - 10 LEVERAGEABLE CAPITAL (sum of lines 6 through 9)

PART lla. ADJUSTMENT TO REGULATORY CAPITAL FOR CAPITAL IMPAIRMENT AND OVERLINE PURPOSES
PART /Ia ONLY APPLIES IF LICENSEE HAS COMPLETED THE REPURCHASE OF ITS 3% PREFERRED STOCK FROM SBA.

11 REGULATORY CAPITAL (Part II, line 6)
12 ADD: Restricted Contributed Capital Surplus (line 49, page 3C)

j
1---------1

13 ADJUSTED REGULATORY CAPITAL FOR CAPITAL IMPAIRMENT AND OVERLINE PURPOSES (line 11 plus line '---------------1

NOTES
(1) Deduct only those organizational expenses which were not accepted as reasonable by SBA.

SBA Form 468 .4 (02/14} Previous edition obsolete.

Page 8C

SCHEDULE OF COMMITMENTS
ASOF

Name of Small Business

SBA Form 468.4 {02/14) Previous ed ition obsolete.

ID

Amount of
Commitment

OMB Approval No. 3245-0063
Expiration Date

Loan, Debt, or
Date Made

l=vnir:atinn Date

New investment or
follow-on?

Page 9C

OMB Approval No. 3245-0063

SCHEDULE OF GUARANTEES
ASOF

Name of Small Business

ID

SBA Form 468.4 (02/14) Previous edition obsolete.

Guarantee
Amount

Date
Made

Fvnir;~tinn

Name of Guaranteed
Date I
Partv

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Is guarantee
collaterialized? If so, by Description of underlying
what?
oblie:ation of Small Business

Page lOC

SCHEDULE 1

SCHEDULE OF LOANS AND INVESTMENTS

OMB Approval No. 3245-0063
Expiration Date mm/dd/yyyy

ASOF
Name of Licensee:

License No.

I

Note: Items in red font only apply to 58/Cs in the Office of Liquidation or as specifically requested by SBA.
Portfolio Company Name

I

Employer ID

Loans and Investments (ordered by date ascending)
Initial mvest.
Investment Date
Investment Type
Amount
Other Notes:
Smaller Enterprise?
Comments:

Warrants?

-

%Own

l.OSt at ISeg. OT
Period

I %Vote I

AOOitiOnS/
Deductions

Unrealized App (Dep)

Cost at End of Period

uescnpt1on or
Addition/Deduction

Number of Shares:
Market/Liquidity:

Expiration Date :

Other type of OL Asset? __ If yes :

LoanLDebt Information
Maturity Date:
Repay. Terms:
Collateral :
Date of Last Payment:
Balloon Payment Due:

Type:
Amount:

SBA Form 468.4 (02/14) Previous ed ition obsolete .

l.OSt at tna OT
Period

unreauzea App
(Dep)

I

Total Reported Value

Reported Value

Class I and II A~~reciation
Class I Appreciation Amount:
Class II Appreciation Amount:
If Class II, Date of Up Round?

Qualifies as start-up per CFR 107.50?1
Equity Capital?!

Eguitl£lnformation
Type of Shares:
Equity Features:

~erms:

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Description of Asset:
Description of Liens:

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Type:l

Status:
Interest Rate:

Balloon% at maturity:
Future Estimated Recoveries:
Date Investment Concluded:

Page 11C

OMB Approval No. 3245-0063

1 A. SUMMARY OF LOANS AND INVESTMENTS

SCHEDULE 1 A/B

Expiration Date mm/dd/yyyy

1 B. SMALLER ENTERPRISE FINANCINGS
ASOF
License No .

Name of Licensee :

1 A. SUMMARY OF LOANS AND INVESTMENTS
2

3

4

5

Cost at Beginning

Additions/

Cost at End of

Appreciation

of Period

(Deductions)

Period

(Depreciation)

1

6

Unrealized
Investment Category

Reported Value

Total Loans (line1, page 2C)
Total Debt Securities (line 2, page 2C)
Total Equity Securities (line 3, page 2C)
Total Portfolio Securities (line 4, page 2C)
'

Total Assets Acquired (line 7, page 2C)
Total Operating Concerns Acquired (line 8, page 2C)
Total Notes and Other Sees. Received (line 9, page 2C)
Total Loans and Investments (line 10, page 2C)
----- - -

1 B. SMALLER ENTERPRISE FINANCINGS

1 Cumulative dollar amount of Smaller Enterprise Financings extended between April 25, 1994 and close of reporting fiscal year.

c----

2 Cumulative dollar amount of all Financing extended between April 25, 1994 and close of reporting fiscal year.

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3 Percentage of total Financings extended to Smaller Enterprises (line 1 divided by line 2)

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1

SEE 13 CFR 107.710 FOR PERCENTAGE OF TOTAL FINANCINGS WHICH MUST BE IN SMALLER ENTERPRISES.

SBA Form 468.4 (02/14) Previous edition obsolete.

Page 12C

SCHEDULE 2

SCHEDULE OF REALIZED GAINS AND

OMB Approval No. 3245-0063

LOSSES ON LOANS AND INVESTMENTS
FOR

Name of Small Business I Employer

ID

/

___

'ransaction Type
Date

I

MONTHS ENDED

Realized

Net Sales
Price

'--

Expiration Date mm/dd/yyyy

Cost

Ga

Cash

Escrow Exp. Comments

(1) Security Type: L= loans, D=Debt, E=Equity, AA=Assets Acquired, OC=Operating concerns acquired, NS=Notes and Other Securities Received

(2) Transaction Type: S= Sale, E=Exchange, C=Charge-off, D=Distribution of Securities
SBA Form 468.4 (02/14) Previous edition obsolete .

Page 13C

SCHEDULE 4

SCHEDULE OF DELINQUENT

OMB Approval No. 3245-0063

LOANS AND INVESTMENTS

Expiration Date mm/dd/yyyy

ASOF

Date of Last P::avml'nt
Name of Small Business I
Emolover ID

Outstanding
Prindn::al Balance

I

Amount Past
Due

I

Days Past
Due Ill

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Amount
Past Due

I

Days Past
Due

Interest

Amount of Last P::avml'nt

Interest

Fair Makrket
Value OF
Collateral

(1) Based on oldest delinquency.
SBA Form 468.4 (02/14) Previous edition obsolete .

Page lSC

SCHEDULE 8

Unaudited Portfolio Company Information

OMB Approval No. 3245-0063

ASOF

Expiration Date mm/dd/yyyy

Name of Licensee :

License No.

I

Note: Items in red font only apply to 58/Cs in the Office of Liquidation or as specifically requested by SBA

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Portfolio Company Name

Employer ID

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%Own

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%Vote

Cost at End of Period

1st Date Invested:
Current stage :

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Exchange:!

NAICS:

Rounded to nearest$

...

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Overline?

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Stock Symbol:

I ... ,
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Addeo'"

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ILMI :

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Tl

Portfolio Com~anl£ Waterfall

Period 3

Revenues
Gross Profit
EBITDA
Interest Charges
Net Income

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Cashflow from Ops.
Burn Rate
Cash Balance
Current Assets
Fixed Assets
Total Assets
Current Liabilities
Debt
Total Liabilities
EOY Equity Value (Market)
EOY Enterprise Value
Additional Information for Most Recent FY End for SBICs in Liauidation
Financial Statement Type :
Statement Opinion :
_ Signficant Litigation
Statement Notes:
_ Going Concern
_Other
If other explain :

Other Comments:

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Pori folio ComDanv Financial Information
Period 1
Period 2

As of Date

If orignal investment company's name changed, was acquired/merged,
company name of original investment: I

City/State:
Zip Code:

Total Reported Value

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General Portfolio Com~anl£lnformation
Business Description

Unrealized App (Dep)

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Economic Data for Recent FY End
Full-time employees:
Federal Taxes Paid:

State Taxes Paid:

Spreadsheet Uploaded:

Instructions: Upload waterfall spreadsheet if you hold an equity investment in the portfolio company or you hold warrants that you have valued over cost. Waterfall information should
minimally include all financings since your initial investment,including those in which you did not participate. Information should include all relevant information associated with each
security, including: date closed, security issued, post-money valuation associated with round, total round size, SBIC's participation within round, co-investors in round (representing over
10% of round), liquidation preferences, seniority, accruing dividends, etc ...
If the SBIC has been transferred to the Office of Liquidation, you must also describe any investor rights you hold, such as negative covenants, board membership or observation rights, or
other rights (such as veto or springing) .

SBA Form 468.4 (02/14) Previous edition obsolete.

Page 20C

QUARTERLY CERTIFICATIONS

OMB Approval No. 3245-0063
Expiration Date mm/dd/yyyy

I

Name of Lice nsee:

License No.

MANAGEMENT CERTIFICATION
I,
the Chief Financial Officer of
(License), do hereby certify that the financial report for the
months ended
submitted by
(Licensee) to the Small Business Administration on SBA
Form 468 is true and correct in all aspects. The statements and schedules listed below have been omitted from
the submission.
STATEMENTS AND SCHEDULES OMITIED:

CAUTION: By signing below, you are certifying as to the truth and accuracy of the Financial Report in all respects, and
acknowledging that officials in the Small Business Administration (SBA) will be relying on this certification. Knowingly
making a false statement to or concealing a material fact from the SBA can lead to imprisonment of up to 30 years and/or a
fine of up to $1,000,000 under 18 U.S.C. § 1014.
By:
Name:
Title :

Date:

.

SECRETARY'S CERTIFICATION
I,

the duly elected, qualified and acting Secretary of
(Licensee), do hereby certify as follows:

1.

(Licensee) is in good standing under the laws of the State of

2. The minutes of the meeting of the Board of Directors of
comoanv for the

(Licensee) on

document that the Board at such meeting, reviewed and approved the Financial Report of such
months ended

CAUTION: By signing below, you are certifying as to the truth and accuracy of the Financial Report in all respects, and
acknowledging that officials in the Small Business Administration (SBA) will be relying on this certification. Knowingly
making a false statement to or concealing a material fact from the SBA can lead to imprisonment of up to 30 years and/or a
fine of up to $1,000,000 under 18 U.S.C. § 1014.
Date:

By:
Name:
Title :

SBA Form 468.4 (02/14) Previous edition obsolete.

Page 21C