Small Business Mentor Protege Programs

OMB Control Number 3245-XXXX

Expiration Date:

U. S. SMALL BUSINESS ADMINISTRATION

Small Business Mentor-Protégé Program

Request for Financial and Other Information

Firms that are interested in participating in the small business mentor-protégé program authorized by 13 CFR 125.9, are required to submit the following information to the Small Business Administration (SBA). This information will be used to determine whether the firms meet the requirements for participation in the all Small Business Mentor Protégé Program. SBA may request further clarification or additional supporting documentation.

Submission of the information is voluntary; however, failure to submit all of the requested information will affect SBA’s ability to properly review your request for approval to participate in the Small Business Mentor-Protégé Program; without SBA’s approval you will be unable to participate in the program.

SBA is required to protect all Personal Identifiable Information (PII) submitted to the extent permissible by law, including the Freedom of Information Act (5 U.S.C.552).

Paperwork Reduction Act Burden Statement: According to the Paperwork Reduction Act, no person is required to respond to a collection of information unless it displays a valid OMB Control Number. The time burden for reporting this collection of information is estimated to average 1 hour. This estimate includes time for reviewing instructions, gathering and submitting the data requested below.

You may send comments regarding the burden estimate or any other aspect of this collection of information to Small Business Administration, Chief, AIB, 409 3rd Street, 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 THE REQUESTED INFORMATION TO OMB.

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1. Documents Required from the PROTÉGÉ:

1. DUNS Number

2. A copy of the firm’s current business plan signed and dated

3. Do you have another (SBA or other Federal Agency) approved Mentor Protégé Agreement? If yes, copies of all agreements.

4. A written statement of explanation on any prior affiliations between both parties, including joint ventures

5. A statement of explanation on current or planned ownership of Protégé firm by Mentor

6. A written statement from each mentor and/or protégé participating in multiple relationships that the mentors and/or protégés are not competitors under the same requirements in those relationships

7. Written Narrative of the Mentor Protégé Relationship, setting forth an assessment of the Protégé’s needs and providing a detailed description and timeline for the delivery of the assistance the Mentor commits to provide to address those needs.

8. A dated written Mentor/Protégé Agreement signed by both parties. (See template at www.sba.gov/aboutsba/sbaprograms/8abd/index.html) ; OMB Control Number to be Assigned)

2. Documents Required from the MENTOR:

   1. Copy of last three years financial statements (audited with notes, preferred); OR

2. Copy of the last three years Federal tax returns (copy of originals that were signed, dated and submitted to the Internal Revenue Service (IRS);

   1. If submitted electronically, provide a copy of the original, signed and dated e-file signature authorization form that was submitted to the IRS. Provide a copy of either IRS Form 8879-PE, IRS e-file Signature Authorization for Form 1065 or IRS Form 8879-C, IRS e-file Signature Authorization for Form 1120 ).

   2. If an extension was requested, provide a copy of the original IRS Form 7004, Application for Automatic 6-Month Extension of Time to File Certain Business Income Tax, Information, and Other Returns, that was signed, dated and submitted to the IRS. Also, provide a copy of the tax forms for the last three years prior to the extension request.

3. Copy of IRS Form 851, Affiliations Schedule (if applicable);

4. Written narrative or executive summary detailing commitment and ability to assist and support Protégé; and is capable of carrying out its responsibilities to assist the protégé firm under the proposed mentor-protégé agreement.

5. DUNS Number

6. List of the three most recent Federal Government contracts or Grants (include Agency name, contract number, North American Industry Classification code, Period of Performance and Dollar Value)

7. Do you have another approved (SBA or other federal Agency) Mentor Protégé Agreement? If yes, copies of all agreements.

8. A written statement of explanation on any prior affiliations between both parties, including joint ventures.

9. A statement of explanation on current or planned ownership of Protégé firm by Mentor

10. A written statement from each mentor and/or protégé participating in multiple relationships that the mentors and/or protégés are not competitors under the same requirements in those relationships