Form SBA Form 1081 SBA Form 1081 Statement of Personal History

OMB APPROVAL NO.: 3245-0080
EXPIRATION DATE: XX-XX-XXXX

U.S. Small Business Administration
STATEMENT OF PERSONAL HISTORY
(FOR USE BY LENDERS)

Please Read Carefully and Fully Complete: SBA uses the Form
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
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.

Lender Name
Lender Address (Street, City, State, Zip Code ) and Email Address

1. First Name

2.

Middle Name (if none, so state)

Date of Birth (month, day & year)

Last Name

3. Place of Birth (City and State or Foreign Country)

4. U.S. Citizen?
Yes
No
5. Social Security Number:
If no, are you a Lawful Permanent resident alien?
Yes
No
If non - U.S. citizen, provide alien registration number:
Country of Citizenship:
6. Starting with present address, attach a list of residence addresses for the last ten years using the following format:
From (Date)

To (Date)

Address

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).
8.

Present Affiliations and/or Associations: Attach a list of all business concerns or entities with which you are presently
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.

SBA Form 1081 (9-16) Previous Edition is Obsolete

Page 1 of 4

IF YOU ANSWER “YES” TO 9a., 9b., 10a., 10b., 10c., 11a., 11b. or 12, FURNISH COMPLETE DETAILS OF
SUCH PROCEEDINGS ON A SEPARATE SHEET. INCLUDE DATES, LOCATIONS, FINES, SENTENCES,
WHETHER MISDEMEANOR OR FELONY, DATES OF PAROLE/PROBATION, INCLUDING, IF PERTINENT, THE
COURT, TITLE OF PROCEEDINGS, DATE AND DOCKET NUMBER, AS WELL AS THE ULTIMATE DISPOSITION.
YES

NO 9a. Have you, or has any business concern or entity with which you are presently or have been Affiliated or
Associated (as defined above), ever been, directly or indirectly, the subject of any insolvency, bankruptcy,
creditor's rights proceedings (including Federal or state tax liens), or other litigation?
9b. Have you, or has any business concern or entity with which you are presently or have been Affiliated or
Associated (as defined above) ever failed to pay when due any debt or obligation, including any amounts in
dispute, to the Federal government or guaranteed by the Federal government (including but not limited to
taxes, business and student loans)?
10a. Are you presently subject to an indictment, criminal information, arraignment, or other means by which
formal criminal charges are brought in any jurisdiction?
10b. Have you been arrested in the past six months for any criminal offense?
10c. For any criminal offense – other than minor vehicle violation – have you ever 1) been convicted;
2) pleaded guilty; 3) pleaded nolo contendere; 4) been placed on pretrial diversion; or 5) been placed on
any form of parole or probation (including probation before judgment)?
11a. Have you, or has any business concern or entity with which you are or have been Affiliated or Associated
(as defined above), ever been charged with or convicted of a felony or other criminal offense involving
fraud, misrepresentation, dishonesty or breach of trust?
11b. Have you, or has any business concern or entity with which you are or have been Affiliated or Associated
(as defined above) ever been a named defendant in any civil legal action (including shareholder litigation),
found civilly liable, or permanently or temporarily enjoined by a court or other regulatory body, by reason of
any act or practice involving fraud, misrepresentation, breach of fiduciary duty or breach of trust?

12. Have you, or has any business concern or entity with which you are or have been Affiliated or Associated
(as defined above) ever been:
i.
Debarred, suspended, proposed for debarment, declared ineligible to participate in, or voluntarily
excluded or revoked from Federal procurement programs and/or Federal non-procurement programs;
ii.
The subject of any suspension, debarment, voluntary exclusion, revocation, or any other regulatory
enforcement action by a state or federal agency, or any other regulatory enforcement body;
iii.
The subject of any other decision by a federal, state or local governmental agency undertaking
administrative enforcement due to fraud, lack of business integrity, ethics violations, or noncompliance
with other governmental requirements; or
iv.
The subject of any investigation or disciplinary hearing or proceeding by a governmental agency,
regulatory body, or professional association?
13. Are you associated with any other SBA Lenders, SBA Microloan Intermediaries or Lender Service Providers
(as defined in 13 CFR 103.1(d))? Are you, or have you been, a direct or indirect owner or 10% or more of
any class of stock, equity interest, voting interest, profit interest, or proprietary interest in any past or
present SBA Lender, SBA Microloan Intermediary or Lender Service Provider? Are you, or have you been,
an officer, director, member of senior management, manager or member of a loan committee of any past or
present SBA Lender, SBA Microloan Intermediary or Lender Service Provider? The term “senior
management” generally refers to an individual’s meaningful participation in the direction of the operations,
policies or financial decisions of a business concern or entity. (If the answer any of the foregoing is “yes,”
please provide the name of the SBA Lender, SBA Microloan Intermediary or Lender Service Provider, your
positions, and the dates.)
14. During any part of the past ten years has a request for financial assistance been made to any federal agency
by you or any business concern or entity with which you are or have been Affiliated or Associated (as
defined above)? (If yes, furnish details in a separate exhibit, including current status of any assistance
received.)

SBA Form 1081 (9-16) Previous Edition is Obsolete

Page 2 of 4

YES

NO 15. To your knowledge, is any SBA employee, any member of an Advisory Council for the Small Business

Administration, or any member of SCORE related to you by blood, marriage, or adoption, or through an
Affiliate or Associate of yours (as defined above)? (If yes, list their names, addresses, and relations.)

16. If you own, or will own 10% or more of any class of the stock or other ownership interest of the SBA Lender
or SBA Microloan Intermediary did you borrow funds to purchase said interest? (If yes, give full details
including your net worth, amount borrowed or to be borrowed, security and/or guarantors, terms of
repayment, and status of loan/debt.)
17. Has any concern with which you are Affiliated or Associated (as defined above) directly or indirectly
borrowed funds from any SBA Lenders, or SBA Microloan Intermediaries? (If yes, give all pertinent details
including the names of all parties to the transaction, the amounts involved, security and/or guarantors, terms
of repayment, use of proceeds, status of loan/debt, etc.)
I authorize the Small Business Administration to request criminal record information about me from criminal justice agencies for the
purpose of determining my eligibility for programs authorized by the Small Business Act and the Small Business Investment Act.

The information on this form will be used in connection with an investigation of your experience and character.
It is against SBA policy to provide assistance not in the best interests of the United States, i.e., if there is reason
to believe that the effect of such assistance will be to encourage or support, directly or indirectly, activities
inimical to the security of the United States.
The nature and scope of the investigation may include contact with banks, other financial institutions,
individuals, business associates, law enforcement offices, and any other areas which will assist SBA in making
an adequate appraisal of your business reputation, character, management experience and financial
soundness. This constitutes the notification required by Section 606 of the Federal Fair Credit Reporting Act.
CAUTION – PENALTIES FOR FALSE STATEMENTS: Knowingly making a false statement on this form is a violation of Federal law and could
result in criminal prosecution, significant civil penalties, and a denial of your program participation. A false statement is punishable under 18 USC
1001 and 3571 by imprisonment of not more than five years and/or a fine of not more than $250,000; and under 15 USC 645 by imprisonment of not
more than two years and/or a fine of not more than $5,000.

Certification: I hereby certify that the foregoing is true and complete to the best of my knowledge and belief.

Signature

Title

Date

PLEASE NOTE: The estimated burden for completing this form is 30 minutes. 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 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 (3245-0080). DO NOT SEND COMPLETED FORMS TO
OMB as that will delay the processing of your application.

FOR SBA USE ONLY
No.

SBA Form 1081 (9-16) Previous Edition is Obsolete

Page 3 of 4

Paperwork Reduction Act (44 U.S.C. Chapter 35) (USE OF INFORMATION)
SBA is collecting the information on this form to make a character determination regarding Associates of Lenders and other individuals
or entities that propose to hold an equity interest of at least 10% of the economic interest in certain Lenders. An Associate is defined as
an officer, director, key employee, or holder of 20 percent or more of the value of the Lender’s stock or debt instruments, or an agent
involved in the loan process (13 CFR §120.10, Definitions). The information also provides the Agency with background data which is
evaluated to determine if the institution’s key personnel have sufficient qualifications in commercial lending activities. The information
collected may be checked against criminal history indices of the Federal Bureau of Investigation.

Privacy Act (5 U.S.C. 552a)
Any person can request to see or get copies of any personal information that SBA has in his or her file when that file is retrieved by
individual identifiers such as name or social security numbers. Requests for information about another party may be denied unless SBA
has the written permission of the individual to release the information to the requestor or unless the information is subject to disclosure
under the Freedom of Information Act.
Under the provisions of the Privacy Act, you are not required to provide your social security number. Failure to provide your social
security number may not affect any right, benefit or privilege to which you are entitled. Disclosures of name and other personal
identifiers are, however, required for a benefit, as SBA requires an individual seeking assistance from SBA to provide it with sufficient
information for it to make a character determination. In determining whether an individual is of good character, SBA considers the
person's integrity, candor, and disposition toward criminal actions. Additionally, SBA is specifically authorized to verify your criminal
history, or lack thereof, pursuant to section 7(a)(1)(B), 15 USC Section 636(a)(1)(B) of the Small Business Act (the Act). Further, for all
forms of assistance, SBA is authorized to make all investigations necessary to ensure that a person has not engaged in acts that violate
or will violate the Act or the Small Business Investment Act, 15 USC Sections 634(b)(11) and 687(b)(a), respectively. For these
purposes, you are asked to voluntarily provide your social security number to assist SBA in making a character determination and to
distinguish you from other individuals with the same or similar name or other personal identifier.
The Privacy Act authorizes SBA to make certain “routine uses” of information protected by that Act. One such routine use for SBA's
investigative files system of records is that when this information indicates a violation or potential violation of law, whether civil, criminal,
or administrative in nature, SBA may refer it to the appropriate agency, whether Federal, State, local or foreign, charged with
responsibility for or otherwise involved in investigation, prosecution, enforcement or prevention of such violations. Another routine use
is disclosure to other Federal agencies conducting background checks; only to the extent the information is relevant to the requesting
agencies' function. See 74 F.R. 14890 (2009), and as amended from time to time for additional background and other routine uses.

Freedom of Information Act (5 U.S.C. 552)
This law provides, with some exceptions, that SBA must supply information reflected in agency files and records to a person requesting
it. Information about approved loans that will be automatically released includes, among other things, statistics on our loan programs
(individual borrowers are not identified in the statistics) and other information such as the names of the borrowers (and their officers,
directors, stockholders or partners), the collateral pledged to secure the loan, the amount of the loan, its purpose in general terms and the
maturity.
Proprietary data on a borrower would not routinely be made available to third parties. All requests under this Act are to be addressed to
the nearest SBA office and be identified as a Freedom of Information request.

SBA Form 1081 (9-16) Previous Edition is Obsolete

Page 4 of 4