SBA Form 1050 SBA Settlement Sheet

SBA SETTLEMENT SHEET FORM 1050

OMB Control No: 3245-0200 Expiration Date: xx/xx/xxxx

Purpose: The purpose of this form is to document and verify that loan proceeds have been disbursed in

accordance with the Authorization and to document that the Borrower’s contribution has been injected into the business prior to the Lender disbursing any loan proceeds.

Requirement: Lenders must use this form for the first disbursements on all standard 7(a) loans.

This form is to be completed by the Lender and signed by the Lender and the Borrower at the time of the initial loan disbursement. If there are subsequent disbursements, Lender must document each disbursement and attach the documentation to the original SBA Form 1050 (a new SBA Form 1050 is not required for each subsequent disbursement). The Lender must retain a copy of the signed form in its loan file. For all disbursements, the Lender must also retain documentation that is acceptable to SBA (such as joint payee checks, cancelled checks, paid receipts or invoices, wire transfer account records, etc.) and evidence of compliance with the Use of Proceeds section of the Authorization.

The Lender must submit the completed form and all supporting documentation to SBA upon request, or, in the event of a loan default, with the Lender’s request for guaranty purchase. Providing this information is required to comply with Loan Program Requirements (as defined in 13 CFR 120.10); failure to provide it when required may impair the Lender’s ability to collect on the SBA loan guaranty.

If additional space is required to complete the form or provide additional details, please attach a separate sheet.

Instructions for Completing the Form:

1. In the first section, fill in all identifying information. For “Loan Type,” check the box to indicate whether the loan is a term loan or line of credit. For “Disbursement Type” check the box to indicate whether the disbursement is “initial disbursement”, “number of disbursements”, or “full disbursement”. Complete the “Use of Proceeds” section with information related to the initial disbursement.

   1. On the line associated with each applicable use of proceeds, indicate:

      1. The name of the payee (must identify the ultimate recipient, not an intermediary such as a title company);

      2. Amount disbursed; and

      3. Remaining amount to be disbursed, in accordance with the Authorization.

   2. For the “Settlement charges/out of pocket costs” line, insert total amount of settlement charges and other out of pocket costs in the appropriate field within the grid. Attach an itemized list of all charges and costs, including the name of payee and amount paid for each charge or cost. (Reminder: SBA Form 159 is required for all fees paid or to be paid by the Lender (except Lender Service Provider fees) and for all fees paid or to be paid by the Applicant to any agent in connection with the SBA loan application.)

   3. For “Other (Explain),” enter any other use of proceeds authorized in the Authorization that is not already listed in the grid, if applicable.

2. Complete the “Borrower’s Injection” section.

   1. For each type of injection, indicate the source.

   2. If the Seller contributed toward required equity, attach a copy of the Note and evidence of full standby for the life of the loan.

   3. Note: The Borrower’s Injection must be in the business bank account prior to any disbursements of loan proceeds.

3. The Lender and the Borrower must review the certifications and execute the form in the space provided.

SBA Form 1050 (XX-XX) Previous Editions Obsolete Page 1 of 3

U.S. Small Business Administration					OMB APPROVAL NO.: 3245-0200
			Settlement Sheet		EXPIRATION DATE: xx/xx/xxxx
SBA Loan Number		Lender Name		Lender FIRS/Location ID Number
SBA Loan Name/Borrower Name				Note Amount
Loan Type: Term Credit Loan Line of Credit
Disbursement Type Initial Disbursement # _______ Disbursement Full Disbursement

Authorized Use of Proceeds:	Name of Payee:	Amount Disbursed:	Authorized Amount Remaining:
Land Acquisition with or without improvements		$ -	$ -
Construction New Expansion Renovation		$ -	$ -
Leasehold Improvements to a property: owned by Applicant owned by others		$	$
Machinery & Equipment		$ -	$ -
Furniture & Fixtures		$ -	$ -
Inventory Purchase		$ -	$ -
Working Capital		$ -	$ -
Export Working Capital (EWCP or Export Express)		$ -	$ -
Support Standby Letter of Credit (EWCP or Export Express)		$	$
Refinance Existing EWCP or Export LOC (EWCP)		$	$
Business Acquisition (Change of Ownership) Asset or Stock		$	$
Pay off SBA Loan SID Other Lender Both		$	$
Pay Notes Payable SID Other Lender Both
Pay Accounts Payable		$	$
SBA Guarantee Fee		$ -	$ -
Settlement Charges/Out of Pocket Costs		$ -	$ -
Other (Explain):		$ -	$ -
Total:		$ -	$ -

Borrower's Injection (including any deposit or earnest money):
Cash	Source:	$ -
Assets	Source:	$ -
Seller contribution toward required equity (on full standby for life of loan)		$ -
Other (Explain):		$ -
Total Borrower Injection:		$ -

Page 2 of 3

At the time of completion of this form, the Lender and the Borrower certify that: The loan proceeds were disbursed and received and will be used in accordance with the Use of Proceeds section of the Authorization, including any and all SBA/Lender approved modifications, and that all required equity or Borrower injections have been made in accordance with the Authorization and any approved modifications; and There has been no unremedied adverse change in the Borrower’s or Operating Company’s financial condition, organization, management, operations or assets since the date of application that would warrant withholding or not making this disbursement or any further disbursement. At the time of each subsequent disbursement on this loan, the Lender, by disbursing the loan proceeds, and the Borrower by receiving them, are deemed to certify that the above certifications are true with respect to each, and every disbursement made.
WARNING: By signing below you are certifying that the above statements and the information you have provided in all supporting documents is true and accurate to the best of your knowledge. Submitting false information to the Government may result in criminal prosecution and fines up to $250,000 and/or imprisonment for up to 5 years under 18 USC § 1001 and/or, under 15 USC § 645, by imprisonment of not more than two years and/or a fine of not more than $5,000. Submitting false statements to a Federally insured institution may result in fines up to $1,000,000 and/or imprisonment for up to 30 years under 18 USC § 1014, . No assurances are provided with this form specifically. However, the “Statements Required by Law and Executive Order” in the attached addendum,” is provided with each 7(a) loan application to advise lenders and loan applicants that, among other things, SBA will protect the sensitive and/or confidential loan related information against disclosure to the extent permitted by law. Such statutory protection may fall under the “Freedom of Information Act” (5 U.S.C. 552), “Privacy Act” (5 U.S.C. 552a), and the “Right to Financial Privacy Act of 1978” (12 U.S.C. 3401). Personally identifiable information collected is maintained in accordance with SBA’s Privacy Act System of Records, System 21- Loan System, which can be accessed at https://www.govinfo.gov/content/pkg/PAI-2017-SBA/xml/PAI-2017-SBA.xml#sba21. SBA has several safeguards to protect this information. Access and use of electronic records is limited to Agency officials acting in their official capacities, with a need-to-know, and to SBA Resource Partners. Access and use by SBA Resource Partners will generally be via the Internet, with restricted password(s)/passcode(s). SBA Resource Partners, their successors, or assigns, will have access only to those individual records that were collected by that particular partner. Information contained in files will be available only to potential asset sale purchasers who have executed a confidentiality agreement. Only SBA employees in the performance of their official duties, who are granted access to the records by Agency issuance of User ID and/or passcode, may amend or review the records. Access and use of paper records is limited to SBA officials acting in their official capacities, with a need-to-know. SBA Resource Partners, their successors, or assigns, will have access only to the individual records that were collected by that particular partner. Information contained in loan files will be available only to potential asset sale purchasers who have executed a confidentiality agreement. Only those SBA employees in the performance of their official duties may review or amend the records.
Authorized Lender Official	Borrower
Signature:	Signature:
Print Name:	Print Name:
Title:	Title:
Date:	Date:

SBA Form 1050 (XX-XX) Previous Editions Obsolete Page 3 of 3

NOTE: According to the Paperwork Reduction Act, you are not required to respond to this collection of information unless it displays a currently valid OMB Control Number. The estimated burden for completing this form, including time for reviewing instructions, and gathering data needed, is 30 minutes. Comments or questions on the burden estimates or other aspects of this information collection should be sent to U.S. Small Business Administration, Director, RMD, 409 3rd St., SW, Washington DC 20416 and/or SBA Desk Officer, Office of Management and Budget, New Executive Office Building, Rm. 10202, Washington DC 20503. PLEASE DO NOT SEND THE COMPLETED FORMS TO THESE ADDRESSES.

Privacy Act (5 U.S.C. 552a) A 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. But see Debt Collection notice below. Disclosures of name and other personal identifiers are 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. 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 687b(a).

The Privacy Act authorizes SBA to make certain “routine uses” of information protected by that Act. One such routine use is the disclosure of information maintained in SBA’s investigative files system of records when this information indicates a violation or potential violation of law, whether civil, criminal, or administrative in nature. Specifically, SBA may refer the information 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 that SBA may disclose the information maintained in SBA’s investigative files to other Federal agencies conducting background check to the extent the information is relevant to the requesting agencies’ function. An additional routine use of personal information is to assist in obtaining credit bureau reports, including business credit reports on the small business borrower and consumer credit reports and scores on the principals of the small business and guarantors on the loan for purposes of originating, servicing, and liquidating small business loans and for purposes of routine periodic loan portfolio management and lender monitoring. In addition, as a routine use, SBA may transfer to the Department of Housing and Urban Development, or other Federal agency, information related to a debt that a person is delinquent in paying to SBA in connection with its loan programs for publication on a computer database system to allow searches by participating Government agencies and approved private lenders, consistent with applicable law. SBA and its authorized lenders may also use this computer database system to perform a computer match to determine a loan applicant’s credit status with participating agencies of the Federal Government. See Revision of Privacy Act System of Records, SBA 21- Loan System, 74 FR 14890 (April 1, 2009) for additional background and other routine uses, as amended by notices published at 77 FR 15835 (3/16/2012) and 77 FR 61467 (10/9/2012), and as may be further amended from time to time.

Note: Any person concerned with the collection, use and disclosure of information, under the Privacy Act may contact the Chief, FOI/ PA Office, 409 3rd Street, SW, Suite 5900, Washington, DC 20416 or by e-mail at foia@sba.gov for information about the Agency's procedures relating to the Privacy Act and the Freedom of Information Act.