SBA Form 1405 Stockholders Confirmation (Corporation) Ownership Confir

U.S. SMALL BUSINESS ADMINISTRATION
REQUEST FOR INFORMATION
STOCKHOLDER CONFIRMATION FOR CORPORATE
SMALL BUSINESS INVESTMENT COMPANIES (SBICs)

OMB Control No. 3245-0172
Expiration Date XX/XX/XXXX

The information requested below obtains voluntary representations from the investors of Small Business Investment
Companies (SBICs) to assist SBA’s oversight of the SBIC program. The information is collected by an SBA Examiner as part
of an examination of the relevant SBIC to determine compliance with applicable statutory and regulatory program provisions.
Confidential information, including commercial or financial information, will be protected from disclosure to the public to the
extent permitted by law, particularly exemptions 4, 6, and 8 of the Freedom of Information Act (5 U.S.C. 552.
Please return completed forms within 10 days, as directed by the requesting SBA Examiner.

TO: SBA EXAMINER
In connection with your SBIC examination, I represent that the following information is accurate regarding the
ownership interest of, ________________________________________________, in the SBIC,
________________________________________________.
1. The records of ______________________ (SBIC) show that as of __________________, the SBIC issued
______ shares of common stock to ______________________ as holder of record for total consideration of
$____________.
_____ Correct _____Incorrect (If incorrect, please explain.)

2a. Your unpaid capital commitment of $__________ is due the SBIC and remains outstanding.
_____ Correct _____Incorrect (If incorrect, please explain.)

2b. Is your capital commitment backed by an outstanding letter of credit from a qualified institutional investor?
_____ Yes
_____ No (If yes, please explain.)

3. Is the SBIC’s capital stock held by you pledged as collateral or encumbered in any other manner?
_____ Yes
_____ No (If yes, please explain.)

4. Have you or do you anticipate receiving directly or indirectly any financing from the SBIC?
_____ Yes
_____ No (If yes, please explain.)

SBA Form 1405 (X-XX) Previous Editions Obsolete

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5. Are there any ‘puts’, ‘calls’, purchase agreements, assignments of voting rights, or other contracts attached
to the stock you hold in the SBIC?
_____ Yes
_____ No (If yes, please explain.)

6. Were the funds used to purchase the SBIC’s capital stock borrowed? If so, please state the source of
borrowed funds and if your net worth is equal to at least twice the amount of the funds borrowed.

WARNING By signing below, you are 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 form is true and correct to the best of my knowledge.

____________________________________________
SIGNATURE AND TITLE

_______________________________
DATE

PLEASE NOTE: This information collection is voluntary. The total estimated burden for completion of this form, including
gathering the information and completing and reviewing the response, is 1 hour. You are not required to respond to this
information collection if a valid OMB control number is not displayed. If you have any questions or comments concerning this
estimate or other aspects of this information collection, please contact the U.S. Small Business Administration, Chief,
Administrative Information Branch, 409 3rd Street, S.W., Washington, DC 20416, or SBA Desk Officer, Office of Management
and Budget, New Executive Office Building, Room 10202, Washington, DC 20503. (OMB Control Number: 3245-0172).
PLEASE DO NOT SEND FORMS TO OMB.
SBA Form 1405 (X-XX) Previous Editions Obsolete

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