SBA Form 2182 Principal Exhibits

OMB Approval No. 3245-0062

Expiration Date: xx/xx/xxxx

409 3^rd St., SW • Washington, DC 20416 • (202) 205-6510

The SBIC Program

Form 2182: Principal Exhibits

Name of Principal:	Enter Full Principal Name
Name of Applicant:	Enter Applicant Name

The estimated burden for completing this form, including all Exhibits, is 80 hours per response for each individual respondent required to complete Exhibits A through F when submitting a Management Assessment Questionnaire and 30 hours per response for each individual respondent required to update Exhibits A through F and complete Exhibits G through J when submitting a License Application.

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 the US Small Business Administration, Chief, Administrative Information Branch, Washington, DC 20416 and Desk Officer for the Small Business Administration, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, DC 20503. OMB Approval 3245-0062.

Please do not send forms to OMB. Refer to Instructions for information on where and how to submit the requested information.

Table of Contents

Table of Contents 2

Notices Required by Law 3

PAPERWORK REDUCTION ACT (44 U.S.C. Chapter 35) 3

FREEDOM OF INFORMATION ACT (5 U.S.C. 552) 4

Exhibits A through F: MAQ & License Application 5

Exhibit A. Experience 5

Exhibit B. Legal Questionnaire 6

Exhibit C. Other SBIC Activities and Relationships 12

Exhibit D. References 14

Exhibit E. Track Record 15

Exhibit F. Portfolio Detail 16

Exhibits G through J: License Application ONLY 17

Exhibit G. Identified Parties & Fingerprint Cards 17

Exhibit H. Statement of Personal History (Individuals) 20

Exhibit I. Statement of Personal History (Entities) 22

Exhibit J. Authorization to Release Information 24

Notices Required by Law

The following is a brief summary of the laws applicable to this collection of information.

PAPERWORK REDUCTION ACT (44 U.S.C. Chapter 35)

Purpose for Collecting Information:

The information requested in Exhibits to the Small Business Investment Company Management Assessment Questionnaire (Exhibits A to F) and License Application (Exhibits A to J) (“Exhibits”) will be used in connection with an investigation of your experience and character. The scope of this investigation may include contact with banks, other financial institutions, individuals, business associates, law enforcement offices (including but not limited to the Federal Bureau of Investigation), and any others that will assist SBA in making an adequate appraisal of your general business reputation and character. SBA may also use the information to assist in obtaining credit bureau reports, including consumer credit reports and scores on the principals of the SBIC applicant, for the purpose of determining whether to approve a principal’s participation in the SBIC program.

If information provided to SBA 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.

Personal information [Privacy Act, 5 U.S.C. 552a]

Any person can request to see or get copies of any personal information that is maintained by SBA. However, requests for information about another individual 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 (5 U.S.C. 552).

Generally, you are not required to provide your social security number and the failure to provide your social security number generally may not affect any right, benefit or privilege to which you are entitled. However, the Debt Collection Improvement Act of 1996 (31 U.S.C. 7701(c)(1)) requires a Federal agency to obtain the taxpayer identification number (TIN) from each person doing business with that agency. Therefore, it is mandatory that you furnish your TIN to SBA as part of your licensing application. Additionally, disclosure of your name and other personal information requested is mandatory. SBA is required under Section 301(c)(3) of the Small Business Investment Act, 15 U.S.C. 681(c)(3), to consider the general business reputation of certain key individuals in order to make a determination about whether each individual has the business experience and character necessary to participate in the SBIC program. Your social security number and other personal identifiers assist SBA in making these determinations required by law. If you do not provide this information, SBA will be unable to reach a favorable determination concerning your participation in the SBIC program.

FREEDOM OF INFORMATION ACT (5 U.S.C. 552)

This law provides, with some exceptions, that we must make records or portions of records contained in our files available to persons requesting them. This generally includes aggregate statistical information on the SBIC program and other information such as names of licensed SBICs and names of companies that have been financed by SBICs. We do not routinely make available to third parties your proprietary data or information that would cause competitive harm or would constitute a clearly unwarranted invasion of personal privacy. We note that Exemptions, 4, 6 and 8 of the Freedom of Information Act (FOIA) allow SBA to withhold financial data on individual companies.

To request information under FOIA, you must send the request to the SBA office maintaining the records requested or the Chief, FOI/PA Office, 409 3rd Street, SW, Washington, DC 20416, or by e-mail to foia@sba.gov, and identify it as a Freedom of Information Act (FOIA) request. The request must describe the specific records you want.

Exhibits A through F: MAQ & License Application

1. Experience

PRIOR TO SUBMITTING THIS DOCUMENT, PLEASE SEE THE “NOTICES REQUIRED BY LAW” ON PAGE 3 OF THESE EXHIBITS FOR EXPLANATIONS ABOUT DISCLOSURE OF INFORMATION AND USES OF SUCH INFORMATION.

Instructions

For each individual, include a resume (not just a narrative) of relevant experience and education, with dates and addresses shown. (The resume belongs in this exhibit and in no other place.) A length of two pages is preferable, but do not exceed three pages.

• Relate your business and professional experience during the past twenty years, as well as any prior experience that relates to your qualifications to manage an SBIC. Give the title of each position, and describe the basic functions and responsibilities.

• Regarding education, list your degrees, major areas of study, and names and addresses of the institutions attended.

• If desired, you may also include any other information that would be considered relevant to demonstrating qualifications for being a principal of an SBIC.

• Delete these instructions prior to submission.

2. Legal Questionnaire

Instructions

1. Submit this exhibit for each principal. Please enter the last name of the principal and the name of the applicant fund in the heading above.

2. Answer all of the following questions. If the answer to any question is “yes”, furnish complete details on a separate sheet, attached to this exhibit. Include all pertinent information, including, name(s) under which charged, dates, locations, titles of proceedings, docket numbers, fines and penalties (paid and unpaid), sentences, type of offense (misdemeanor or felony), dates of parole/probation, and relevant documents.

3. For the purposes of this exhibit, a “substantial ownership interest” in an organization is considered to be an interest, direct or indirect, of 20% or more as reflected in equity interests, voting interests, or profit interests. The term “senior management” generally refers to meaningful participation in budget or investment decisions. If you have questions about whether or not you would have been considered part of senior management, discuss the issue with an SBA program development analyst, licensing analyst, or operations analyst.

4. This exhibit must be signed when submitted as part of either a MAQ or a license application. Any changes in the responses between the MAQ and the license application should be noted and explained.

NOTE: Questions B1 through B3 are repeated in Exhibit H and should be answered in both instances.

Questionnaire

Have you ever been charged with or arrested for any criminal offense other than a minor motor vehicle violation (including offenses that have been dismissed, discharged, expunged, or not prosecuted)?	YES ☐ NO ☐
Have you ever been convicted, placed on pretrial diversion, or placed on any form of probation (including adjudication withheld pending probation) for any criminal offense other than a minor motor vehicle violation?	YES ☐ NO ☐
Have you ever been found civilly liable or permanently or temporarily enjoined by a court or other regulatory body by reason of any act or practice involving fraud or breach of trust?	YES ☐ NO ☐
Has any organization either while you were a member of senior management or when you had a substantial ownership interest, ever been indicted for, charged with, or convicted of any criminal offense involving fraud, breach of fiduciary duty or breach of trust?	YES ☐ NO ☐
Has any organization, either while you were a member of senior management or when you had a substantial ownership interest, ever been found liable, convicted or permanently or temporarily enjoined by a court, by reason of any act or practice involving fraud, breach of fiduciary duty or breach of trust?	YES ☐ NO ☐
Are you now the subject of any investigation or disciplinary hearing or proceeding by a governmental agency, regulatory body, or professional association?	YES ☐ NO ☐
Have you ever been the subject of any investigation or disciplinary hearing or proceeding by a governmental agency, regulatory body, or professional association?	YES ☐ NO ☐
Are you now or have you ever been the subject of any suspension, debarment, or any other regulatory enforcement, or any other regulatory enforcement action by a State or Federal agency based on fraud, lack of business integrity, or violation or noncompliance with regulations or other governmental requirements?	YES ☐ NO ☐
Has any organization, either while you were a member of senior management or when you had a substantial ownership interest, ever been the subject of any investigation or disciplinary hearing or proceeding by a governmental agency, regulatory body, or professional association?	YES ☐ NO ☐
Is any organization of which you are currently a member of senior management, or in which you have a substantial ownership interest, now the subject of any investigation or disciplinary proceeding by a governmental agency, regulatory body, or professional association?	YES ☐ NO ☐
Have you ever entered into an agreement concerning, or otherwise consented to any order or decree by a court, governmental agency or regulatory body in connection with, any federal or state securities law?	YES ☐ NO ☐
Has any organization, either while you were a member of senior management or when you had a substantial ownership interest, ever entered into an agreement concerning, or otherwise consented to any order or decree by a court, governmental agency or regulatory body in connection with any federal or state securities law?	YES ☐ NO ☐
During the past 10 years, have you been a named defendant in any civil legal action involving commercial disputes or creditor's claims (including but not limited to debt collection lawsuit, foreclosure, receivership, and involuntary liquidation) of greater than $500,000 for corporate liabilities or greater than $100,000 for personal liabilities?	YES ☐ NO ☐
If “yes”, did the subject matter involve your personal conduct or fall within your area of responsibility?	YES ☐ NO ☐
If the answer to question B13 is “yes”, were you active in settlement negotiations or arbitration?	YES ☐ NO ☐
Have you, as a result of your role as a member of senior management or as a member of the board of directors of any entity been a named defendant in any civil legal action involving (i) shareholder litigation, (ii) fraud or misrepresentation, or (iii) breach of fiduciary duty?	YES ☐ NO ☐
If “yes”, did the subject matter involve your personal conduct or fall within your area of responsibility?	YES ☐ NO ☐
If the answer to question B14 is “yes”, were you active in settlement negotiations or arbitration?	YES ☐ NO ☐
Have you, in your individual capacity, ever been a named defendant in any civil legal action involving (i) shareholder litigation, (ii) fraud or misrepresentation, or (iii) breach of fiduciary duty?	YES ☐ NO ☐
During the past 10 years, have you filed voluntarily, or had filed against you involuntarily, a bankruptcy petition?	YES ☐ NO ☐
During the past 10 years, has any organization, either while you were a member of senior management or when you had a substantial ownership interest, filed voluntarily, or had filed against such organization involuntarily, a bankruptcy petition?	YES ☐ NO ☐
Have you ever failed to pay when due any debt or obligation, including any amounts in dispute, to the Federal government or any state government, or guaranteed by the Federal government or any state government (including but not limited to taxes, business loans, student loans, etc.)?	YES ☐ NO ☐
Has any organization, either while you were a member of senior management or when you had a substantial ownership interest, ever failed to pay when due any debt or obligation, including any amounts in dispute, to the Federal government or any state government, or guaranteed by the Federal government or any state government (including but not limited to taxes, business loans, educational loans, etc.)?	YES ☐ NO ☐

PRIOR TO SIGNING THIS DOCUMENT, PLEASE SEE THE “NOTICES REQUIRED BY LAW” ON PAGE 3 OF THESE EXHIBITS FOR EXPLANATIONS ABOUT DISCLOSURE OF INFORMATION AND USES OF SUCH INFORMATION.

Certification

I certify that all of the information I have provided on this Exhibit B and any other information I have submitted in connection with this Exhibit B is true, correct and complete to the best of my knowledge. I understand that knowingly making a false statement is a violation of Federal law and could result in criminal prosecution under 18 USC §§ 287, 371, 1001, 1006, and 1014, including fines in excess of $1 million and up to 30 years imprisonment, 15 USC §§ 645 and 687(f), civil penalties under 31 U.S.C. § 3729, government-wide debarment or suspension, and denial, suspension, or revocation of a Small Business Investment Company license.

I have read the “Notices Required by Law” and I authorize the U.S. Small Business Administration to request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for the Small Business Investment Company program.

Printed Name/ Title
Signature		Date	Click here to enter a date.

Commentary

If you answered “yes” to any of the questions in Exhibit B, please provide additional detail here. Please be sure to reference the question to which your commentary applies.

3. Other SBIC Activities and Relationships

Instructions

Submit this Exhibit for each principal.

Questionnaire

1. If you own, or will own, 10% or more of the Private Capital (13 CFR 107.50) of the SBIC, were any of the funds used, or to be used, in purchasing said Private Capital, borrowed? YES ☐ NO ☐

   1. If “Yes”, give full details, including your net worth, amount borrowed or to be borrowed, source of funds borrowed or to be borrowed, terms of repayment, security and/or guarantors.

Click here to enter text.

2. Are you, or have you been?

An investor of 10% or more in another SBIC?	YES ☐ NO ☐
An officer, director, member, manager or principal of an SBIC, a general partner of an SBIC, or the investment advisor/manager or an SBIC?	YES ☐ NO ☐
An employee of an SBIC, the general partner of an SBIC, or the investment advisor/manager of an SBIC?	YES ☐ NO ☐
A member of any investment committee or advisory committee of an SBIC?	YES ☐ NO ☐

If you answered “Yes” to any of the four questions above, please provide the name of the SBIC, your positions, and the dates of affiliation.

1. SBIC Fund I – Investment Committee Member – 4/08 to 5/12

2. SBIC Fund II – 10% or more Investor – 9/97 to 7/05

3. Are you a Close Relative (13 CFR 107.50) of any person Affiliated (13 CFR 121.103) with the Applicant or of any SBIC? YES ☐ NO ☐

1. If “Yes”, provide the name of the SBIC and the relationship.

Click here to enter text.

4. To the best of your knowledge and belief, during the past ten years, has any organization, either while you were a member of senior management or when you had a substantial direct or indirect ownership interest (20% or greater):

Borrowed funds from or sold securities to any Small Business Investment Company?	YES ☐ NO ☐
Received a loan from or guaranteed by the SBA?	YES ☐ NO ☐

If you answered “Yes” to either of the two questions above, please describe below, giving all pertinent details, including the names of all parties to the transaction, dates, amounts involved, terms, use of proceeds, etc., and the outcomes of the financings.

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4. References

PRIOR TO SUBMITTING THIS DOCUMENT, PLEASE SEE THE “NOTICES REQUIRED BY LAW” ON PAGE 3 OF THESE EXHIBITS FOR EXPLANATIONS ABOUT DISCLOSURE OF INFORMATION AND USES OF SUCH INFORMATION.

Instructions

Exhibit D should be completed using the Excel file titled “Form 2182 – Exhibit D.” Only one file should be submitted, containing all of the references for all of the principals. DO NOT submit a separate file for each principal.

5. Track Record

PRIOR TO SUBMITTING THIS DOCUMENT, PLEASE SEE THE “NOTICES REQUIRED BY LAW” ON PAGE 3 OF THESE EXHIBITS FOR EXPLANATIONS ABOUT DISCLOSURE OF INFORMATION AND USES OF SUCH INFORMATION.

Instructions

Exhibit E should be completed using the Excel file titled “Form 2182 – Exhibit E1” and “Form 2182 – Exhibit E2.”

6. Portfolio Detail

PRIOR TO SUBMITTING THIS DOCUMENT, PLEASE SEE THE “NOTICES REQUIRED BY LAW” ON PAGE 3 OF THESE EXHIBITS FOR EXPLANATIONS ABOUT DISCLOSURE OF INFORMATION AND USES OF SUCH INFORMATION.

Instructions

For each of the investment funds included in “Exhibit E: Track Record”, please submit the supporting documentation listed below in ELECTRONIC format only. Hard copies will not be accepted. If this documentation is not included with your application, please provide a brief explanation.

1. The most recent annual reporting package and the most recent quarterly reporting package sent to limited partners.

2. An investment memorandum for an investment included in Exhibit E that is representative of the primary type of investment planned by the applicant. If your prior experience consists of investments different from those planned by the applicant, you may submit an investment memorandum that illustrates your experience. If you believe that additional examples would help SBA to fully understand your capabilities, you many submit additional investment memoranda, but no more than three.

3. “Wind-Up Plan” for each active fund, including (i) the remaining number of years you expect the fund to operate, (ii) the expected liquidation date and anticipated proceeds for each remaining investment, (iii) the timing and amount of any planned reduction in your management expenses, and (iv) the timing of repayments on any obligations outstanding to SBA (if applicable).

4. For all active funds, provide an aging report for any on- or off-balance sheet interest receivables.

Exhibits G through J: License Application ONLY

7. Identified Parties & Fingerprint Cards

PRIOR TO SUBMITTING THIS DOCUMENT, PLEASE SEE THE “NOTICES REQUIRED BY LAW” ON PAGE 3 OF THESE EXHIBITS FOR EXPLANATIONS ABOUT DISCLOSURE OF INFORMATION AND USES OF SUCH INFORMATION.

Instructions

1. In Table G1 below, please list:

1. All officers and directors of a corporate SBIC, general partners of a limited partnership SBIC, or managers of an LLC SBIC. (Note that if the general partner of a limited partnership SBIC or the manager of an LLC SBIC is an entity, then all of the managers of the entity must be listed.)

2. All individuals or entities that exercise "Control" (as defined in 13 CFR 107.50) or who are “Control Persons” (as defined in 13 CFR 107.50).

3. All individuals or entities that own or control, directly or indirectly, thirty-three percent (33%) or more of the outstanding securities (or equivalent ownership interests) of the SBIC.

4. All investment committee members and any individual whose role is highly influential (SBA liaison, officers and employees of the applicant’s investment advisor/manager with day-to-day management responsibility and/or signing authority for the applicant).

5. The three ranking managers or officers of any entity described in (2) or (3) above.

2. Indicate the following:

1. In the column labeled “Code”, enter a category number from the choices directly above.

2. In the column “Role in the SBIC” insert a few words describing each party’s role in the SBIC

3. Place an “X” in the FPC box for each individual required to be fingerprinted. (See Guidelines for Fingerprint Cards below).

3. Each individual listed in Table G1 must submit an Exhibit H, Statement of Personal History – Individuals, and each entity listed in Table G1 must submit an Exhibit I, Statement of Personal History – Entities. Each individual required to be finger-printed must submit two (2) signed fingerprint cards (Form FD-258) with all fields completed. If a listed entity is newly formed, it is not necessary to submit Exhibit I; next to the entity name in Table G1, indicate “new” and give the date of formation.

Table G1: Parties Required to Submit Additional Information

Individual/Entity	Code	Role in the SBIC	FPC

Guidelines for Fingerprint Cards

GENERAL RULE: Unless one of the exemptions below applies, each individual listed in Table G1 must submit two (2) signed fingerprint cards. Please be advised that SBA, in its sole discretion, may require a Statement of Personal History and fingerprint cards from any person associated with the SBIC applicant, even if that person is not listed in Table G1.

Note that fingerprint card form FD-258 must be used and must be preprinted with SBA’s agency identification. These forms can be obtained directly from SBA through a program development analyst, operations analyst, or by sending an email request to sbic@sba.gov.

EXEMPTIONS: The entities listed below are exempt from the requirement that their three ranking managers submit fingerprint cards and statements of Personal History. However, any manager who has an arrest record must submit fingerprint cards and a Statement of Personal History regardless of these exemptions.

1. Companies registered under the Investment Company Act of 1940.

2. Advisors registered under the Investment Advisors Act of 1940.

3. Broker-Dealers registered under the Securities and Exchange Act of 1934.

4. Federal Home Loan Banks.

5. National banks regulated by the Office of the Comptroller of the Currency, FDIC members, or federal savings associations regulated by the Office of Thrift Supervision.

6. Any company subject to regulation under the Bank Holding Company Act or regulated as a Financial Holding Company under the Gramm-Leach-Bliley Act.

7. U.S. subsidiaries of foreign banks that take deposits in the U.S., provided the subsidiary has a net worth of at least $10 million.

8. Foreign banks that do NOT accept deposits in the U.S. and which have a net worth of $50 million or greater, and have publicly available audited financial statements.

9. Domestic insurance companies with a minimum of $10 million of surplus.

10. Any corporation (domestic or foreign) whose stock (or ADRs) trades on the New York Stock Exchange.

11. Any company required to file periodic reports with the Securities and Exchange Commission under Section 15(d) or 12(g) of the Securities and Exchange Act of 1934 and whose net worth is $20 million or greater, and whose stock trades on the American Stock Exchange or the NASDAQ National Market.

12. State and local government agencies.

13. State and local government retirement plans.

14. Employee benefit plans covered by ERISA with assets of at least $50 million.

15. Entities tax-exempt under §501(c)(3) of the Internal Revenue Code with assets of $10 million or greater, net of liabilities.

16. Foreign entities substantially equivalent to those exempted above, as determined by the SBA.

Example of a Fingerprint Exemption: Assume the following structure:

• The starting point in this analysis is the recognition that LP#1 is an entity investor which has a 33% ownership interest in SBIC. Therefore, under the Item No. A3 of the instructions on the first page of this exhibit, this entity is required to be listed in Table B1.

• As an entity investor, LP#1 is required to list its three ranking managers or officers in Table B1 (see Item No. A5), and under the fingerprint guidelines, each ranking manager of LP#1 is required to submit fingerprint cards, unless an exemption applies.

• Since, however, LP#1 is owned by a registered broker-dealer under the Securities and Exchange Act of 1934, the managers or officers of the registered broker-dealer are exempt from the fingerprint requirement, and because an exemption has been reached, the analysis for this investor can stop.

8. Statement of Personal History (Individuals)

SBIC	H1. Applicant or Licensee Name
	Address: Street, City, State, Zip Code
	Tel:		Fax		Email

H2a. First Name in Full	Middle Name(s) in Full (If “none”, so state)			Last Name
H2b. List All Former Name(s) and Any Other Current Names Used (If “none”, so state)			From (Date)		To (Date)
H2c. List current and any former or other social security numbers (SSNs) used and names associated with these numbers. (If no other SSNs used, so state.)

H3a. Date of Birth (Month, Day, Year)
H3b. Place of Birth (City, State, Country)
H3c. Citizen of U.S.?			Yes					No
H3d. If a U.S. citizen	Native Born		Naturalized					N/A
H3e. If naturalized, date, city, state and the naturalization or citizenship certificate number								N/A
H3f. If you are not a citizen of the U.S., are you a permanent resident alien?			Yes		No			N/A
H3g. If “yes” to H3f, provide the date you entered the U.S., the location (city and state) and your alien registration number								N/A

H4. Starting with your present address, list all residence addresses for the last ten years.

From (Date)	To (Date)	Address

If the answer to H5, H6, or H7 is “yes,” attach complete details to this exhibit. Include dates, location, fines and penalties (paid and unpaid), sentences (misdemeanors or felony), dates of parole/probation, name(s) under which charged, and any other pertinent information.

Are you presently under indictment or on parole or probation?	YES ☐ NO ☐
Have you ever been charged with or arrested for any criminal offense other than a minor motor vehicle violation (including offenses that have been dismissed, discharged, expunged, or not prosecuted)?	YES ☐ NO ☐
Have you ever been convicted, placed on pretrial diversion, or place on any form of probation (including adjudication withheld pending probation) for any criminal offense other than a minor motor vehicle violation?	YES ☐ NO ☐

If the answer to H8 is “yes,” attach complete details of proceeding(s) to this exhibit (including the indictment or complain and the court, title of proceeding, date and docket number).

Have you ever been found civilly liable or permanently or temporarily enjoined by a court or other regulatory body by reason of any act or practice involving fraud or breach of trust?

YES ☐ NO ☐

PRIOR TO SIGNING THIS DOCUMENT, PLEASE SEE THE “NOTICES REQUIRED BY LAW” ON PAGE 3 OF THIS FORM FOR EXPLANATIONS ABOUT DISCLOSURE OF INFORMATION AND USES OF SUCH INFORMATION.

Certification

I certify that all of the information I have provided on this Exhibit H and any other information I have submitted in connection with this Exhibit H is true, correct and complete to the best of my knowledge. I understand that knowingly making a false statement is a violation of Federal law and could result in criminal prosecution under 18 USC §§ 287, 371, 1001, 1006, and 1014, including fines of up to $1 million and up to 30 years imprisonment, 15 USC §§ 645 and 687(f), civil penalties under 31 U.S.C. § 3729, government-wide debarment or suspension, and denial, suspension, or revocation of a Small Business Investment Company license.

I have read the “Notices Required by Law” and I authorize the U.S. Small Business Administration to request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for the Small Business Investment Company program.

Printed Name/ Title
Signature		Date	Click here to enter a date.

9. Statement of Personal History (Entities)

SBIC	I1. Applicant or Licensee Name
	Address: Street, City, State, Zip Code
	Tel:		Fax		Email

I2. Legal Name of Entity
I3. List all former name(s) and addresses, EINs, and any other trade names used and addresses used. (If “none”, so state)
I4. Headquarters Address (Physical Address)
I5. Name of Contact Person					Title
I6. Telephone No.			Fax			Email

I7. Date of Organization		EIN
I8. State/Foreign Country of Organization

List the three ranking officers/managers with their respective titles.

Name	Title

[continued on next page]

PRIOR TO SIGNING THIS DOCUMENT, PLEASE SEE THE “NOTICES REQUIRED BY LAW” ON PAGE 3 OF THIS FORM FOR EXPLANATIONS ABOUT DISCLOSURE OF INFORMATION AND USES OF SUCH INFORMATION.

Certification

I certify that all of the information I have provided on this Exhibit I and any other information I have submitted in connection with this Exhibit I is true, correct and complete to the best of my knowledge. I understand that knowingly making a false statement is a violation of Federal law and could result in criminal prosecution under 18 USC §§ 287, 371, 1001, 1006, and 1014, including fines of up to $1 million and up to 30 years imprisonment, 15 USC §§ 645 and 687(f), civil penalties under 31 U.S.C. § 3729, government-wide debarment or suspension, and denial, suspension, or revocation of a Small Business Investment Company license.

I have read the “Notices Required by Law” and I authorize the U.S. Small Business Administration to request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for the Small Business Investment Company program.

Printed Name/ Title
Signature		Date	Click here to enter a date.

10. Authorization to Release Information

PRIOR TO SUBMITTING THIS DOCUMENT, PLEASE SEE THE “NOTICES REQUIRED BY LAW” ON PAGE 3 OF THESE EXHIBITS FOR EXPLANATIONS ABOUT DISCLOSURE OF INFORMATION AND USES OF SUCH INFORMATION.

Instructions

This form must be signed for each principal of the SBIC entity and/or fund sponsor(s) as part of the License Application only. A signed original and two copies must be submitted for each person.

Declaration

In connection with an application for an SBIC license, or operation of an SBIC, I hereby authorize the U.S. Small Business Administration (“SBA”) and its agents to make inquiries, including obtaining a consumer report from a consumer reporting agency, to determine by person credit standing.

A photographic copy of this authorization (being a photographic copy of the original signature of the undersigned) is equivalent to the original and may be considered a duplicate original.

Printed Name/ Title
Signature		Date	Click here to enter a date.

SBA Form 2182 (07-13) Previous editions obsolete 1 of 24