Form SBA Form 2460 SBA Form 2460 MENTOR-PROTEGE BENEFITS REPORT

OMB Control Number: 3245-XXXX

Expiration Date:

Small Business Administration

MENTOR-PROTÉGÉ BENEFITS REPORT

Use of Information: Each Protégé participating in the Small Business Mentor-Protégé Program is required to report annually to the Small Business Administration on the status of its mentor-protégé relationships. The information includes identification of the technical, management and/or financial assistance received from the mentor and a description of how that assistance has impacted the protégé’s development. Each mentor is also required to disclose in Part B of this form any adverse actions or activities that could impact the mentor’s ability to continue in the mentor-protégé relationship. The information will help SBA to determine how the protégé is benefiting from the relationship and whether to continue to approve the mentor-protégé agreement.

Once a mentor-protégé relationship ends, the protégé must submit a final report to SBA on whether the protégé believed the mentor-protégé relationship was beneficial and describe any lasting benefits it received.

All information collected will be protected to the extent permitted by law, including the Freedom of Information Act, (5 U.S.C. 522), Privacy Act (5 U.S.C. 555a) and the Right to Financial Privacy Act of 1978 (12 U.S.C. 3401).

Submission Requirements: Reports are to be submitted to [address will be inserted after creation of website]

Paperwork Reduction Act Burden Statement: No person is required to respond to a collection of information unless it displays a valid OMB Control Number. The time burden for this collection of information is estimated to average 2 hours per response, including time for gathering the data needed, and completing and reviewing the responses. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to, 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. DO NOT SEND REPORTS TO OMB.

PART A [To be Completed by the Protégé]:

NAME OF FIRM:

BUSINESS CATEGORY: ___WOSB ___ EDWOS ___HUBZONE ___ SDVOSB ___SB ____SDB

FIRM ADDRESS:

PRIMARY POINT OF CONTACT:

TELEPHONE NUMBER: E-MAIL ADDRESS:

Your firm participated in or continues to participate in an approved mentor-protégé agreement with [insert name and address of mentor:]_________________________________________________________________________

Date this agreement was approved: ___________Period of agreement: ______________

1. List all technical and/or management assistance provided by the mentor to the protégé.

2. List all financial assistance including loans to and/or equity investments made by the mentor to the protégé;

3. List all business development assistance provided by the mentor.

(iv) List all contracting assistance including subcontract awarded to the protégé by the mentor including the value;

i List all federal contracts awarded to the mentor/protégé relationship as a joint venture, (designating each as an Small Business, HUBZone, SDB, Service Disabled Veteran Owned, Women Owned, Economically Disadvantaged Women Owned, or unrestricted procurement), the value of each contract, contract number, and the percentage of revenue accrued to each party to the joint venture and a list of past performance:

(v) List all general and administrative assistance provided to the protégé by the mentor.

5. Provide a short narrative (1) detailing all contracts it has performed in conjunction with its mentor; and (2) list the success and/or failures of referenced contracts.

(vi) Provide a list of the mentoring services the protégé received by category and whether or not the proposed timeline were met.

PART B [To be Completed by the Mentor]:

If your firm is a Mentor, are there any pending adverse actions (such as lawsuits, delinquent taxes, bankruptcy filings, creditor problems, contract disputes, suspension/debarment from federal contracting of the firm, etc.) which may affect your business operation, good character, and/or favorable financial position?: Yes ___ No ____

If yes, please explain below or on a separate page if needed.

PART C [Certifications]:

BY SIGNING BELOW, I CERTIFY THAT ALL INFORMATION SUBMITTED IN THIS SMALL BUSINESS MENTOR-PROTÉGÉ BENEFITS REPORT AND ANY ATTACHMENTS IS TRUE, CORRECT AND ACCURATE. I UNDERSTAND THAT FALSE STATEMENTS CAN BE SUBJECT TO PROSECUTION UNDER 18 U.S.C. § 1001 AND OTHER STATUTES, CAN SUBJECT ME OR MY COMPANY TO TREBLE DAMAGES UNDER THE FALSE CLAIMS ACT, 31 U.S.C. §§ 3729–3733 OR SUSPENSION OR DEBARMENT, AND CAN RESULT IN THE TERMINATION OF MY COMPANY FROM THE SMALL BUSINESS MENTOR PROTÉGÉ PROGRAM.

For the Protégé

________________________________________ __________________

Signature of President, Officer or Authorized Official Date

For the Mentor:

________________________________________ __________________

Signature of President, Officer or Authorized Official Date

SBA FORM 2460 (03/2016)