Get SBA 912 2019-2024

OMB APPROVAL NO. 3245-0178 Expiration Date 04/30/2016 United States of America SMALL BUSINESS ADMINISTRATION STATEMENT OF PERSONAL HISTORY Name and Address of Applicant Firm Name Street City State and ZIP Code Please Read Carefully SBA uses Form 912 as one part of its assessment of program eligibility. Please reference SBA Regulations and Standard Operating Procedures if you have any questions about who must submit this form and where to submit it. SBA 912 2-2013 SOP 5010. 4 Previous Edition Obsolete NOTICES REQUIRED BY LAW The following is a brief summary of the laws applicable to this solicitation of information. Paperwork Reduction Act 44 U.S.C. Chapter 35 SBA is collecting the information on this form to make a character and credit eligibility decision to fund or deny you a loan or other form of assistance. Chapter 35 SBA is collecting the information on this form to make a character and credit eligibility decision to fund or deny you a loan or other form of assistance. The information is required in order for SBA to have sufficient information to determine whether to provide you with the requested assistance. If you wish to submit comments on the burden for completing this form direct these comments to U.S. Small Business Administration Chief AIB 409 3rd 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 3245-0178. DO NOT SEND COMPLETED FORMS TO OMB as this will delay the processing of your application send forms to the address provided by your lender or SBA representative. SBA 912 2-2013 SOP 5010. 4 Previous Edition Obsolete NOTICES REQUIRED BY LAW The following is a brief summary of the laws applicable to this solicitation of information. Paperwork Reduction Act 44 U.S.C. When the information collected on this form 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. You are not required to respond to any collection of information unless it displays a currently valid OMB approval number. If you wish to submit comments on the burden for completing this form direct these comments to U.S. Small Business Administration Chief AIB 409 3rd 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 3245-0178. DO NOT SEND COMPLETED FORMS TO OMB as this will delay the processing of your application send forms to the address provided by your lender or SBA representative. 10. I authorize the 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 programs authorized by the Small Business Act and the Small Business Investment Act. CAUTION - PENALTIES FOR FALSE STATEMENTS Knowingly making a false statement on this form is a violation of Federal law and could result in criminal prosecution significant civil penalties and a denial of your loan surety bond or other program participation. A false statement is punishable under 18 USC 1001 and 3571 by imprisonment of not more than five years and/or a fine of up to 250 000 under 15 USC 645 by imprisonment of not more than two years and/or a fine of not more than 5 000 and if submitted to a Federally insured institution under 18 USC 1014 by imprisonment of not more than thirty years and/or a fine of not more than 1 000 000. Signature Title Agency Use Only Fingerprints Waived Fingerprints Required Date Sent to OIG Date Approving Authority Cleared for Processing Request a Character Evaluation Required whenever 7 8 or 9 are answered yes even if cleared for processing. PLEASE NOTE The estimated burden for completing this form is 15 minutes per response.