Form SBA Form 856 SBA Form 856 DISCLOSURE STATEMENT LEVERAGED LICENSEES

U.S. SMALL BUSINESS ADMINISTRATION (SBA) DISCLOSURE STATEMENT LEVERAGED LICENSEES

OMB CONTROL NO. 3245-0118 EXPIRATION DATE XX/XX/XX

The information collected below obtains representations from the management of a Small Business Investment Company (SBIC) regarding certain obligations, transactions and relationships as part of an onsite examination of the SBIC. Providing this information is required for compliance with 13 CFR § 107.691. Failure to do so may subject the SBIC to fees as authorized by 13 CFR §107.692. Please return completed forms as directed by the requesting SBA Examiner.

TO: SBA EXAMINER

In connection with your examination of , as of

, I represent that to the best of my knowledge that all of the following information is accurate: (Write “None” where applicable and expand rows where necessary.)

1. All known liabilities of this licensee were recorded on the books of account except for the following:

2. No litigation was in progress or pending, or is now in progress or pending, except for the following:

3. The licensee has not provided financings to any concerns which have also received financing from Associates (as defined in 13 CFR Section 107.50) except for the following:

4. No assets of the licensee were pledged or otherwise hypothecated as security for any liability except:

5. No licensee capital stock (or licensee partnership interest) was pledged or encumbered except:

6. The licensee is guaranteeing the following portfolio company loans: (List name of company, amounts guaranteed, and payments made.)

7. Outstanding financing commitments are:

8. The licensee or its Associates provided management consultant services, technical services, services as a member of the board of directors or any of the services of the type described in 13 CFR Section 107.900, to the following portfolio companies:

NAME OF PORTFOLIO COMPANY	NAME OF SERVICE PROVIDER (LICENSEE OR ASSOCIATE)	DATE SERVICES BEGAN	DESCRIPTION OF FEES PAID BY PORTFOLIO COMPANY

SBA FORM 856 (XX/XX) REF SOP 10 09 PREVIOUS EDITIONS ARE OBSOLETE

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9. The licensee or its Associates assumed Control (as defined in 13 CFR Section 107.50) over the following portfolio companies:

10. The licensee’s Associates are also officers, directors, or employees (or partners) of portfolio companies as follows:

NAME OF PORTFOLIO COMPANY	NAME OF ASSOCIATE	POSITION IN PORTFOLIO COMPANY	DATE POSITION TAKEN

11. The licensee’s Associates have direct or indirect financial interest in portfolio companies as follows:

NAME OF PORTFOLIO COMPANY AND DESCRIPTION OF FINANCIAL INTEREST, STOCK OWNERSHIP, WARRANTS, PARTNERSHIP INTEREST, LOAN, ETC.	DATE FINANCIAL INTEREST ACQUIRED	COST BASIS	NAME OF ASSOCIATE

12. The licensee’s Associates received title to or use of (with or without financial consideration) assets from portfolio companies or from the licensee as follows:

WARNING By signing below, you are certifying as to the accuracy of information you have provided on or with this statement. You are further acknowledging that a representative for the U.S. Small Business Administration (SBA) and the SBA are relying on this information, and that false statements can lead to criminal prosecution under 18

U.S.C. 1014, and other statutes, with fines of up to $1,000,000 and imprisonment of up to 30 years, and civil fraud damages of three times the Government’s loss.

I hereby certify that all information provided in this disclosure statement, and all information and documents that I have provided along with this disclosure statement, are true and correct to the best of my knowledge.

SIGNATURE AND TITLE DATE

PLEASE NOTE: The estimated burden for completing this form, including gathering and complying the information, is 60 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, Director, Records Management Division, 409 3^rd 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 (3245-0118). PLEASE DO NOT SEND FORMS TO OMB.