SBA Form 2181 SBIC MAQ Exhibit D Individual Legal Questionnaire

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Overview

Notices Required by Law
Individual Legal Questionnnaire
Identified Parties
Statement of Personal History

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Sheet 1: Notices Required by Law

Notices Required by Law
The following is a brief summary of the laws applicable to this collection of information.

PAPERWORK REDUCTION ACT (44 U.S.C. Chapter 35)
Purpose for Collecting Information: The information requested in this Form 2181 (including, but not limited to, Exhibits A through G and the Management Assessment Questionnaire) will be used in connection with an investigation of your experience and character. The scope of this investigation may include contact with banks, other financial institutions, individuals, business associates, law enforcement offices (including the Federal Bureau of Investigation), and any others that will assist SBA in making an adequate appraisal of your general business reputation and character. SBA may also use the information to assist in obtaining credit bureau reports, including consumer credit reports and scores on the principals of the SBIC applicant, for the purpose of determining whether to approve a principal’s participation in the SBIC program. If information provided to SBA indicates a violation or potential violation of law, whether civil, criminal, or administrative in nature, SBA may refer it 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.

Personal information (Privacy Act, 5 U.S.C. 552a)
Any person can request to see or get copies of any personal information that is maintained by SBA. However, requests for information about another individual 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 (5 U.S.C. 552). Generally, you are not required to provide your social security number and the failure to provide your social security number generally may not affect any right, benefit or privilege to which you are entitled. However, the Debt Collection Improvement Act of 1996 (31 U.S.C. 7701(c)(1)) requires a Federal agency to obtain the taxpayer identification number (TIN) from each person doing business with that agency.). Therefore, it is mandatory that you furnish your TIN to the SBA as part of your licensing application. Additionally, disclosure of your name and other personal information requested is mandatory. SBA is required under Section 301(c)(3) of the Small Business Investment Act, 15 U.S.C. 681(c)(3), to consider the general business reputation of certain key individuals in order to make a determination about whether each individual has the business experience and character necessary to participate in the SBIC program. Your social security number and other personal identifiers assist SBA in making these determinations required by law. If you do not provide this information, SBA will be unable to reach a favorable determination concerning your participation in the SBIC program.

Freedom of Information Act (U.S.C. 552)
This law provides, with some exceptions, that we must make records or portions of records contained in our files available to persons requesting them. This generally includes aggregate statistical information on the SBIC program and other information such as names of licensed SBICs and names of companies that have been financed by SBICs. We do not routinely make available to third parties your proprietary data or information that would cause competitive harm or would constitute a clearly unwarranted invasion of personal privacy. We note that Exemptions, 4, 6 and 8 of the Freedom of Information Act (FOIA) allow SBA to withhold financial data on individual companies. To request information under FOIA, you must send the request to the SBA office maintaining the records requested or the Chief, FOI/PA Office, 409 3rd Street, SW, Washington, DC 20416, or by e-mail to foia@sba.gov, and identify it as a Freedom of Information Act (FOIA) request. The request must describe the specific records you want

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Sheet 2: Individual Legal Questionnnaire

Individual Legal Questionnaire

As of Date:

MM/DD/YYYY

You are required to submit this exhibit for each principal. Answer all of the following questions. If the answer to any question is “yes”, furnish complete details and provide any necessary attachments. Include all pertinent information, including, name(s) under which charged, dates, locations, titles of proceedings, docket numbers, fines and penalties (paid and unpaid), sentences, type of offense (misdemeanor or felony), dates of parole/probation, names of mediators, arbitrators or other alternative dispute resolution professionals, and relevant documents. For the purposes of this exhibit, a “substantial ownership interest” in an organization is considered to be an interest, direct or indirect, of 20% or more in equity interests, voting interests, or profit interests. The term “senior management” generally refers to meaningful participation in budget or investment decisions, including participation as a member of the board of directors. If you have questions about whether or not you would have been considered part of senior management, discuss the issue with SBA Office of Investment and Innovation. This exhibit must be signed when submitted as part of either a MAQ application and/or a Final License application. Any changes in the responses between the MAQ application and the Final License application should be noted and explained.

Name of Applicant:

Name of Principal:

[First]

[Last]

1

Have you ever been charged with or arrested for any criminal offense other than a minor motor vehicle violation (including offenses that have been dismissed, discharged, expunged, or not prosecuted or settled through plea deal or other similar process)?

2

Have you ever been convicted, placed on pretrial diversion, entered into a plea deal or other similar process, or placed on any form of probation (including adjudication withheld pending probation) for any criminal offense other than a minor motor vehicle violation?

3

Have you ever ever (a) been found civilly liable, (b) entered into a settlement through mediation, arbitration or other alternative dispute resolution process or (c) been permanently or temporarily enjoined by a court or other regulatory body by reason of any act or practice involving fraud or breach of trust?

4

Has any organization either while you were a member of senior management or when you had a substantial ownership interest, ever been indicted for, charged with, entered into a plea deal for, or convicted of any criminal offense involving fraud, breach of fiduciary duty or breach of trust?

5

Has any organization, either while you were a member of senior management or when you had a substantial ownership interest, ever been found liable, convicted or permanently or temporarily enjoined by a court, or entered into a settlement agreement for by mediation, arbitration or other alternative dispute resolution process by reason of any act or practice involving fraud, breach of fiduciary duty or breach of trust?

6

Are you now the subject of any investigation or disciplinary hearing or proceeding by a governmental agency, regulatory body, or professional association?

7

Have you ever been the subject of any investigation or disciplinary hearing or proceeding by a governmental agency, regulatory body, or professional association?

8

Are you now or have you ever been the subject of any suspension, debarment, or any other regulatory enforcement, or any other regulatory enforcement action by a State or Federal agency based on fraud, lack of business integrity, or violation or noncompliance with regulations or other governmental requirements?

9

Has any organization, either while you were a member of senior management or when you had a substantial ownership interest, ever been the subject of any investigation or disciplinary hearing or proceeding by a governmental agency, regulatory body, or professional association?

10

Is any organization of which you are currently a member of senior management, or in which you have a substantial ownership interest, now the subject of any investigation or disciplinary proceeding by a governmental agency, regulatory body, or professional association?

11

Have you ever entered into an agreement concerning (through mediation, arbitration, other alternative dispute resolution process or similar process), or otherwise consented to any order or decree by a court, governmental agency or regulatory body in connection with, any federal or state securities law?

12

Has any organization, either while you were a member of senior management or when you had a substantial ownership interest, ever entered into an agreement concerning (through mediation, arbitration, other alternative dispute resolution process or similar process), or otherwise consented to any order or decree by a court, governmental agency or regulatory body in connection with any federal or state securities law?

13

During the past 10 years, have you been a named defendant in any civil legal action involving commercial disputes or creditor's claims (including but not limited to debt collection lawsuit, foreclosure, receivership, and involuntary liquidation) of greater than $500,000 for corporate liabilities or greater than $100,000 for personal liabilities?

If “yes”, did the subject matter involve your personal conduct or fall within your area of responsibility?

If the answer is “yes”, were you active in settlement negotiations or arbitration?

14

Have you, as a result of your role as a member of senior management or as a member of the board of directors of any entity been a named defendant in any civil legal action involving (i) shareholder litigation, (ii) fraud or misrepresentation, or (iii) breach of fiduciary duty?

If “yes”, did the subject matter involve your personal conduct or fall within your area of responsibility?

If the answer is “yes”, were you active in settlement negotiations or arbitration?

15

Have you, in your individual capacity, ever been a named defendant in any civil legal action involving (i) shareholder litigation, (ii) fraud or misrepresentation, or (iii) breach of fiduciary duty?

16

During the past 10 years, have you filed voluntarily, or had filed against you involuntarily, a bankruptcy petition?

17

During the past 10 years, has any organization, either while you were a member of senior management or when you had a substantial ownership interest, filed voluntarily, or had filed against such organization involuntarily, a bankruptcy petition?

18

Have you ever failed to pay when due any debt or obligation, including any amounts in dispute, to the Federal government or any state government, or guaranteed by the Federal government or any state government (including but not limited to taxes, business loans, student loans, etc.)?

19

Has any organization, either while you were a member of senior management or when you had a substantial ownership interest, ever failed to pay when due any debt or obligation, including any amounts in dispute, to the Federal government or any state government, or guaranteed by the Federal government or any state government (including but not limited to taxes, business loans, educational loans, etc.)?

CERTIFICATION AND AUTHORIZATION TO RELEASE INFORMATION

I certify that all of the information I have provided on this Individual Legal Questionnaire and any other information I have submitted in connection with this Individual Legal Questionnaire is true, correct and complete to the best of my knowledge. I understand that knowingly making a false statement is a violation of Federal law and could result in criminal prosecution under 18 USC §§ 287, 371, 1001, 1006, and 1014, including fines of up to $1 million and up to 30 years imprisonment, 15 USC §§ 645 and 687(f), civil penalties under 31 U.S.C. § 3729, government-wide debarment or suspension, and denial, suspension, or revocation of a Small Business Investment Company license.

In connection with an application for an SBIC license, or operation of an SBIC, I hereby authorize the U.S. Small Business Administration (“SBA”) and its agents to make inquiries, including obtaining a consumer report from a consumer reporting agency, to determine by person credit standing.

I have read the “Notices Required by Law” and I authorize the U.S. Small Business Administration Office of Inspector General to request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for the Small Business Investment Company program.

20

Printed Name

21

Title

22

Signature

23

Date

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Sheet 3: Identified Parties

Identified Parties

As of Date:

MM/DD/YYYY

In the table below, please identify: 1) All officers and directors of a corporate SBIC, general partners of a limited partnership SBIC, or managers of an LLC SBIC. (Note that if the general partner of a limited partnership SBIC or the manager of an LLC SBIC is an entity, then all of the managers of the entity must be listed.) 2) Individuals or entities that exercise "Control" or who are “Control Persons” (both as defined in 13 CFR 107.50) of the Licensee, the General Partner of the Licensee, including limited partners with greater than fifty percent (50%) or more of the unfunded and funded commitments to the Licensee. 3) All investment committee members and any individual whose role is highly influential (SBA liaison, officers and employees of the applicant’s investment adviser/manager with day-to-day management responsibility and/or signing authority for the applicant). 4) The three ranking managers or officers of any entity described in (1) or (2) above.

Name of Applicant:

Name of Principal:

[First]

[Last]

Individual or Entity Name

Code (Select from one of the four categories above)

Role in the SBIC

to add rows add above row 18

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Sheet 4: Statement of Personal History

Statement of Personal History

As of Date:

MM/DD/YYYY

Each principal and individual identified on the "Identified Parties" tab is required to submit and execute this Statement of Personal History. Answer all of the following questions. If the answer to any question is “yes”, furnish complete details and provide any necessary attachments. Include all pertinent information, including, name(s) under which charged, dates, locations, titles of proceedings, docket numbers, fines and penalties (paid and unpaid), sentences, type of offense (misdemeanor or felony), dates of parole/probation, names of mediators, arbitrators or other alternative dispute resolution professionals, and relevant documents.

Name of Applicant:

[Name Here]

Name of Principal:

[First]

[Last]

SBIC

Applicant or Licensee Name

[Name Here]

Address: Street, City, State, Zip Code

[Street Address]

[City]

[State XX]

[Zip Code]

Telephone:

(###) ###-####

Email

First Name in Full

Middle Name(s) in Full (If “none”, so state)

Last Name

List All Former Name(s) and Any Other Current Names Used (If “none”, so state)

From (Date)

To (Date)

MM/DD/YYYY

MM/DD/YYYY

List current and any former or other social security numbers (SSNs) used and names associated with these numbers. (If no other SSNs used, so state.)

Date of Birth (Month, Day, Year)

MM/DD/YYY

Place of Birth (City, State, Country)

Citizen of U.S.? (Y/N)

If a U.S. citizen

Native Born (Y/N)?

If naturalized, date, city, state and the naturalization or citizenship certificate number

MM/DD/YYYY

City, State

If you are not a citizen of the U.S., are you a permanent resident alien?

If “yes” to "permanent resident alien", provide the date you entered the U.S., the location (city and state) and your alien registration number

MM/DD/YYYY

City, State

Starting with your present address, list all residence addresses for the last ten years.

From (Date)

To (Date)

Address

MM/DD/YYYY

MM/DD/YYYY

Street, City, State, Zip

1

Have you ever been charged with or arrested for any criminal offense other than a minor motor vehicle violation (including offenses that have been dismissed, discharged, expunged, or not prosecuted or settled through plea deal or other similar process)?

2

Have you ever been convicted, placed on pretrial diversion, entered into a plea deal or other similar process, or placed on any form of probation (including adjudication withheld pending probation) for any criminal offense other than a minor motor vehicle violation?

3

Have you ever ever (a) been found civilly liable, (b) entered into a settlement through mediation, arbitration or other alternative dispute resolution process or (c) been permanently or temporarily enjoined by a court or other regulatory body by reason of any act or practice involving fraud or breach of trust?

CERTIFICATION AND AUTHORIZATION TO RELEASE INFORMATION

I certify that all of the information I have provided on this Statement of Personal History and any other information I have submitted in connection with this Statement of Personal History is true, correct and complete to the best of my knowledge. I understand that knowingly making a false statement is a violation of Federal law and could result in criminal prosecution under 18 USC §§ 287, 371, 1001, 1006, and 1014, including fines of up to $1 million and up to 30 years imprisonment, 15 USC §§ 645 and 687(f), civil penalties under 31 U.S.C. § 3729, government-wide debarment or suspension, and denial, suspension, or revocation of a Small Business Investment Company license.

I have read the “Notices Required by Law” and I authorize the U.S. Small Business Administration Office of Inspector General to request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for the Small Business Investment Company program.

Printed Name

Title

Signature

Date