SBA Form 1010-Indi Individual Information

SBA Form 1010-Individual
OMB Approval No. 3245-0331
Expiration Date: xx/xx/xxxx

INDIVIDUAL INFORMATION
Owners and Other Individuals: This form must be completed by:
8(a) Applicant(s): The applicant’s 51% owner(s) and all other individuals claiming social and economic disadvantage
status to qualify the firm. Note: 8(a) Applicants must complete Sections A, B, and C.
Other Individuals: Each individual owning at least 10% of the applicant firm and each director, management member,
partner, and officer of the applicant firm must complete this form and attach the support documents as required.
Note: These Individuals must complete only Section A.
NOTE: This form must be included as part of the 8(a) application package that includes other forms such as SBA Forms
1010, 413, etc…
NOTICE OF CRIMINAL PENALTIES AND ADMINISTRATIVE REMEDIES FOR FALSE STATEMENTS:
Under Title 18 U.S.C. § 1001 and Title 15 U.S.C. § 645, any person who misrepresents a business concern’s status as an 8(a) Program Participant, or makes any
other false statement in order to influence the certification process in any way, or to obtain a contract awarded under the preference programs established pursuant
to section 8(a), 8(d), 9 or 15 of the Small Business Act, or any other provision of Federal Law that reference Section 8(d) for a definition of program eligibility
shall be: (1) Subject to fines and imprisonment of up to 5 years, or both, as stated in Title 18 U.S.C. § 1001; (2) subject to fines of up to $500,000 and
imprisonment of up to 10 years, or both, as stated in Title 15 U.S.C. § 645; (3) Subject to civil and administrative remedies, including suspension and debarment;
and (4) Ineligible for participation in programs conducted under the authority of the Small Business Act.

Name: ___________________________________

Gender: [ ] Male [ ] Female

Marital Status: ____________________________
Home Address: _______________________________________________________________________
City: _____________________ County: _____________ State: ______________ Zip: ______________
Name of Applicant Firm (include any trade or d.b.a. names):
___________________________________________________________________________________________
Your Position(s) in the Business: Director [ ]

Partner [ ]

Officer [ ] position(s) ____________________________

Owner [ ] percentage owned:_______%
Other: ____________________________________

Are you authorized to make withdrawals from, or have access to, the Applicant Firm’s bank account?

NOTE REGARDING 1010-IND SECTIONS A AND B: Please attach a detailed explanation, including supporting
documentation for each question answered “Yes” and include the question number on the attachment.

SBA Form 1010-IND (XX/15)

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SBA Form 1010-Individual
OMB Approval No. 3245-0331
Expiration Date: xx/xx/xxxx

SECTION A
Section A must be completed by the 8(a) Applicant(s) and Other Individuals: This section must be
completed by the applicant’s 51% owner(s) and all other individuals claiming social and economic disadvantage status to qualify
the firm as well as each individual owning at least 10% of the applicant firm and each director, management member, partner, and
officer of the applicant firm.

QUESTIONS:
1. Have you filed for personal bankruptcy within the past 7 years? If yes, provide a brief
explanation and a copy of the bankruptcy court’s final order or discharge.

[ ]Yes

[ ]No

2. Have you previously obtained an SBA loan? If yes, provide the name(s) of the borrower(s)
on the loan, date approved (or estimate), and current status of the loan.

[ ]Yes

[ ]No

3. Are you a party to a pending civil lawsuit? If yes, summarize your interest in the suit, a
summary of the claims, and the current status of the suit.

[ ]Yes

[ ]No

4. If you are not the 8(a) applicant, were you the former employer of the 8(a) applicant?

[ ]Yes

[ ]No

5. If you are not the 8(a) applicant, were you the former majority owner (51% or more) of the
applicant firm?

[ ]Yes

[ ]No

6. a) Other than any publicly traded stocks, bonds, and mutual funds you may own, do you
have an ownership interest in any other business(es),
b) Are you an officer or director in any other business(es)?
If yes, provide the following for each business: (1) your percentage of ownership; (2) the
business’s revenues for the past three years.

[ ]Yes

[ ]No

[ ]Yes

[ ]No

7. Are you an employee of the federal government holding a position of GS-13 or above?
If yes, you must submit a letter of no objection from your federal agency. See 13 CFR
§ 105.301.

[ ] Yes

[ ] No

8. Were you born outside of the United States? If yes, provide evidence of U.S. citizenship.

[ ]Yes

[ ]No

9. a) Do you have any delinquent Federal (or Federally backed) obligations?
b) Do you have any past due taxes or liens?
c) Have you been delinquent in filing your personal Federal or local tax returns?
If yes, your explanation must include a discussion of and copies of any tax liens or
unsatisfied judgments, evidence of repayment arrangements and proof of compliance with
repayment arrangements. If dismissed or if you have satisfied all liens, provide proof.

[ ]Yes
[ ]Yes
[ ]Yes

[ ]No
[ ]No
[ ]No

10. Have you previously used your one time 8(a) eligibility to qualify a business for the 8(a) BD Program?

[ ]Yes

[ ]No

11. Do you have an immediate family member (see definition on Form 1010) who has ever held an
ownership interest (full or partial) in another business that was admitted to the 8(a) BD
program? If yes, your statement must include the identity of the family member, the name of
the business, the NAICS code that the business was approved under, and describe the
percentage of any ownership interest.

[ ]Yes

[ ]No

SBA Form 1010-IND (XX/15)

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SBA Form 1010-Individual
OMB Approval No. 3245-0331
Expiration Date: xx/xx/xxxx

 Checklist - Additional document(s) required.


Everyone completing this form must submit the following documents:
SBA Form 912, “Statement of Personal History,” (When completing this form, if you
answer ‘Yes’ to SBA Form 912 questions # 7, 8, or 9 you must also provide a completed
FD-258, Fingerprint Card and a narrative providing all details for each arrest/incident,
and copies of any available court disposition(s)/document(s).

SBA Form 1010-IND (XX/15)

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SBA Form 1010-Individual
OMB Approval No. 3245-0331
Expiration Date: xx/xx/xxxx

SECTION B
Section B must be completed by the 8(a) Applicant(s) only: This section must be completed by the
applicant’s 51% owner(s) and all other individuals claiming social and economic disadvantage status to qualify the firm.

1. Is any member of your household an employee of the federal government holding a position [ ]Yes
of GS-13 or above?
If yes, you must submit a letter of no objection from the federal agency employing the family
member. See 13 CFR § 105.301.
2. Have you transferred any personal assets during the last two years to any immediate family
member for less than fair market value? If yes, provide a detailed explanation, including the [ ] Yes
nature and amount of the asset(s) transferred and the recipient of each transferred asset.
3. Are you currently employed outside the applicant firm?
If yes, provide information on this employment and evidence that the activity does not conflict with the
day-to-day management of the applicant business concern. Please indicate the number of hours per
week and the normal working hours of this outside employment.

[ ]Yes

[ ]No

[ ]No
[ ]No

4. Identify the presumed socially disadvantaged group of which you are a member. See 13 CFR § 124.103(b).
Black American[ ]

Hispanic American[ ]

Subcontinent Asian American[ ]

*Native American[ ]

Asian Pacific American[ ]

*None of the above[ ]

*Note 1: If Native American, identify Federally or state recognized Indian tribe, provide a copy of the tribal card.
*Note 2: If you answered “none of the above” to question 4, you are not presumed to be socially disadvantaged and
you must provide a narrative statement demonstrating chronic and substantial discriminatory treatment sufficient to
meet the social disadvantage requirement. See Section C below for guidance on social disadvantage narratives.

 Checklist - Additional documents required for the 8(a) Applicant(s).


A completed SBA Form 413, “Personal Financial Statement,” no older than 30 days, for the individual
claiming disadvantage and a separate SBA Form 413 for his/her spouse, dividing all assets and liabilities
as appropriate.



Personal Resume, including education, technical training and business and employment experience
(employer’s name, dates of employment and nature of employment). Your resume must include a
description of your current duties within the applicant firm.



Copies of your personal filed Federal income tax returns (including all schedules, W-2 forms, and proof
of tax paid, if owed) for the three years immediately preceding the application for yourself and your
spouse (if filing separately).

SBA Form 1010-IND (XX/15)

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SBA Form 1010-Individual
OMB Approval No. 3245-0331
Expiration Date: xx/xx/xxxx

SECTION C

Social Disadvantage Narrative
This section must be completed by the 8(a) Applicants that answered “none of the above” to question 4. You are not presumed
to be socially disadvantaged and you must provide a narrative statement demonstrating chronic and substantial
discriminatory treatment sufficient to meet the social disadvantage requirement. See 13 CFR § 124.103 and the 8(a) BD
website (www.sba.gov).

1. Identify the objective distinguishing feature on which you are basing your social disadvantage. See 13 CFR
§ 124.103(c)(2)(i)).







Race _______
Ethnic Origin__________________
Physical Handicap _____________
Long term residence in an environment isolated from mainstream of American society ________
Gender __________________
Other_______________

2. Has your disadvantage been rooted in treatment which has been experienced in American Society? See 13 CFR
§ 124.103(c)(2)(ii))



Yes
No

3. Please attach a narrative statement (preferably no longer than three pages) providing specific claims or incidents of
bias or discriminatory conduct directed towards you. These claims must detail (1) when and where the incident
occurred, (2) who committed the act, (3) how the incident took place, and (4) how the incident negatively impacted
your entry into and/or advancement in the business world. Please note that you must provide more than one specific,
significant incident in order to establish chronic and substantial social disadvantage.

SBA Form 1010-IND (XX/15)

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SBA Form 1010-Individual
OMB Approval No. 3245-0331
Expiration Date: xx/xx/xxxx

NOTICE OF CRIMINAL PENALTIES AND ADMINISTRATIVE REMEDIES FOR FALSE STATEMENTS:
Under Title 18 U.S.C. § 1001 and Title 15 U.S.C. § 645, any person who misrepresents a business concern’s status as an
8(a) Program Participant, or makes any other false statement in order to influence the certification process in any way, or
to obtain a contract awarded under the preference programs established pursuant to section 8(a), 8(d), 9 or 15 of the Small
Business Act, or any other provision of Federal Law that reference Section 8(d) for a definition of program eligibility shall
be: (1) Subject to fines and imprisonment of up to 5 years, or both, as stated in Title 18 U.S.C. § 1001; (2) subject to fines
of up to $500,000 and imprisonment of up to 10 years, or both, as stated in Title 15 U.S.C. § 645; (3) Subject to civil and
administrative remedies, including suspension and debarment; and (4) Ineligible for participation in programs conducted
under the authority of the Small Business Act.

CERTIFICATIONS: By signing this form, I certify that:
•

I have reviewed the responses to all questions on this form and all supporting documents required by this form,
and that all responses and documents are true and complete to the best of my knowledge.

•

I understand that SBA is relying on this information in making its determination of the applicant company’s
eligibility for the 8(a) BD Program.

___________________________
Signature

________________________
Print Name

__________________
Date

The estimated burden for completing this form, including reading the instructions and gathering the
information, is 1 hour for initial application and each annual update. (A submission for reconsideration is
estimated to require approximately 30 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, Chief, AIB, 409 3rd St., S.W., Washington D.C. 20416, and/or SBA Desk
Officer, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C.
20503. PLEASE DO NOT SEND FORMS TO OMB.

SBA Form 1010-IND (XX/15)

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