Sba Form 1010-ind Individual Information

OMB Approval No. 3245-0331

Expiration Date: xx/xx/xxxx

OMB Approval No. 3245-0331

Expiration Date: xx/xx/xxxx

INDIVIDUAL INFORMATION

Each person owning more than 10% of the applicant firm and each director, management member, partner, and officer of the applicant firm must complete this form and attach the documents required below.

YOUR SIGNATURE ON THIS FORM INDICATES THAT YOU FULLY UNDERSTAND ALL QUESTIONS AND CERTIFIES THAT ALL RESPONSES AND DOCUMENTS ARE TRUTHFUL AND ACCURATE.

Name: ___________________________________ Gender: [ ] Male [ ] Female

Home Address: _______________________________________________________________________

City: _____________________ County: _____________ State: ______________ Zip: ______________

Name of Applicant Firm (include any trade or d.b.a. names): ___________________________________________________________________________________________

Your Position(s) in the Business: Director [ ] Partner [ ] Owner [ ] percentage owned:_________

Officer [ ] position(s) ____________________________ Other: ____________________________________

Average Number of Hours per Week Devoted to Working at the Business: ________

Are you authorized to make withdrawals from, or have access to, the business concern’s bank account?

[ ] Yes [ ] No

Note: You must attach a detailed explanation, including supporting documentation, noting the question number for each “yes” response to the following questions 1 - 12.

Have you filed for personal bankruptcy in the past 7 years? If yes, provide details and a copy of the bankruptcy court’s final order or discharge.	[ ]Yes	[ ]No
Have you previously obtained an SBA loan? If yes, provide the name(s) of the borrower(s) on the loan, date approved, and current status of the loan.	[ ]Yes	[ ]No
Have you ever been an owner, stockholder, or guarantor for a business concern which has received an SBA loan? If yes, provide the name(s) of the borrower(s) on the loan, date approved, and current status of the loan.	[ ]Yes	[ ]No
Are you a party to any pending civil lawsuit? If yes, summarize your interest in the suit, a summary of the claims, and the current status of the suit.	[ ]Yes	[ ]No
Are you a former employer or an officer of a former employer, of any individual(s) claiming disadvantage?	[ ]Yes	[ ]No
Other than any publicly traded stock, bonds, and mutual funds you may own, do you have an ownership interest in any other business, and/or are you an officer or director in any other business concern? If yes, provide the following information: (1) identify your percentage of ownership in that(those) concern’s (s’); (2) identify the number of employees in that(those) concern(s); (3) identify that(those) concern(s) revenues for the past three years; and (4) identify all other owners, partners, directors, officers, and principal stockholders in that(those) concern(s) by name, address, position held, and percentage of any ownership interest.	[ ]Yes	[ ]No
Are you, or is any member of your household, a Federal employee?	[ ]Yes	[ ]No
Were you born outside of the United States? If yes, provide evidence of U.S. citizenship.	[ ]Yes	[ ]No
Do you have any delinquent Federal obligations, past due taxes or liens or have you been delinquent in filing your personal Federal or local tax returns? If yes, your explanation must include a discussion of and copies of any tax liens or unsatisfied judgments, evidence of repayment arrangements and proof of compliance with repayment arrangements.	[ ]Yes	[ ]No
Have you previously used your socially disadvantaged status to qualify a business concern for the 8(a) BD Program or have you ever been an owner (full or partial), director, officer or partner in another business concern that was admitted to the 8(a) BD program? If yes, your narrative statement must include the name of the other business concern and describe the percentage of any ownership interest in that business concern.	[ ]Yes	[ ]No
Has an immediate family member (see definition on Form 1010) ever been an owner (full or partial) of another business concern that was admitted to the 8(a) BD program? If yes, your narrative statement must include the name of the business concern and describe the percentage of any ownership interest.	[ ]Yes	[ ]No
Have you ever been debarred, suspended, voluntarily excluded or otherwise the subject of an action that rendered you ineligible for procurement or non-procurement purposes from any department or agency of the Federal Government? If yes, provide a brief description of the cause of action.	[ ]Yes	[ ]No

All persons signing this form must provide the following documents:

• Personal Resume, including the education, technical training and business and employment experience (employer’s name, dates of employment and nature of employment). Your resume must include a description of your current duties within the applicant business concern.

• Copies of your personal Federal income tax returns (including all schedules and W-2 forms) for the two years immediately preceding the application for yourself and your spouse (if filing separately)., and an executed IRS form 4506-T, Request for Transcript of Tax Return, for yourself and your spouse (if filing separately). The tax returns must be signed and dated.

Note for AIT- or ANC-owned business concerns: Only individuals owning 10% or more of the applicant business concern need to submit two years of Federal income tax returns.

• A completed SBA Form 912, “Statement of Personal History,” (include required Form FD-258, Fingerprint Card, for affirmative answers to questions 7, 8, and 9 on the SBA Form 912), a narrative providing all details for each arrest/incident, and copies of any available court disposition(s)/document(s).

Additionally, persons claiming to be socially and economically disadvantaged in order to qualify the applicant business concern for the 8(a) BD Program must answer questions 13 – 15 and provide the documents listed below:

Have you transferred any personal assets during the last two years to any immediate family member for less than fair market value? If yes, provide a detailed explanation, including the nature and amount of the asset(s) transferred and the recipient of each transferred asset.	[ ]Yes	[ ]No
Are you currently employed outside the applicant firm? If yes, provide information on this employment and evidence that the activity does not conflict with the day-to-day management of the applicant business concern. Please indicate the number of hours per week and the normal working hours of this outside employment.	[ ]Yes	[ ]No
Identify which of the following presumed socially disadvantaged group(s) you are in (you should review 13 C.F.R. § 124.103(b) before answering): Black American [ ] Hispanic American [ ] Native American [ ] Asian Pacific American [ ] Subcontinent Asian Americans [ ] None of the above [ ] (If none of the above, follow instructions on next page) If Native American, identify whether Federally or state recognized Indian tribe and indicate tribal card number:_________________________________________________________________________________ If you answered “none of the above” to question 15, you are not presumed to be socially disadvantaged, and you must provide a narrative statement – and evidence – demonstrating discriminatory treatment sufficient to meet the social disadvantage requirement. See 13 C.F.R. § 124.103 and the 8(a) BD website (see Internet address on page 1 of the Form 1010).

• A narrative statement describing your economic disadvantage. See 13 C.F.R. § 124.104.

• A completed SBA Form 413, “Personal Financial Statement,” no older than 30 days, for the individual claiming disadvantage and a separate SBA Form 413 for his/her spouse, dividing all assets and liabilities as appropriate. If the individual claiming disadvantage is married and lives in a community property state, evidence of which assets and income are community property and which are separate must be provided.

NOTICE OF CRIMINAL PENALTIES AND ADMINISTRATIVE REMEDIES FOR FALSE STATEMENTS: Under Title 18 U.S.C. § 1001 and Title 15 U.S.C. § 645, any person who misrepresents a business concern’s status as an 8(a) Program participant, or makes any other false statement in order to influence the certification process in any way, or to obtain a contract awarded under the preference programs established pursuant to section 8(a), 8(d), 9 or 15 of the Small Business Act, or any other provision of Federal Law that reference Section 8(d) for a definition of program eligibility shall be: (1) Subject to fines and imprisonment of up to 5 years, or both, as stated in Title 18 U.S.C. § 1001; (2) subject to fines of up to $500,000 and imprisonment of up to 10 years, or both, as stated in Title 15 U.S.C. § 645; (3) Subject to civil and administrative remedies, including suspension and debarment; and (4) Ineligible for participation in programs conducted under the authority of the Small Business Act.

CERTIFICATIONS: By signing this form, I certify that

• I have reviewed the responses to all questions on this form and all supporting documents required by this form, and that all responses and documents are true and complete to the best of my knowledge.

• I understand that SBA is relying on this information in making its determination of my company’s eligibility for the 8(a) BD Program.

• I have not previously used my socially and economically disadvantaged status to qualify another company for the 8(a) BD Program.

___________________________ ________________________ __________________

Signature Print Name Date

PLEASE NOTE: The estimated burden for completing this form is 1 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 3rd St., S.W., Washington D.C. 20416.

SBA Form 1010 (-)

2

SBA Form 1010-IND (xx/xx)