Principal Name
Social Security Number or
Tax ID if an Entity
Date of Birth
Place of Birth
(City & State or Foreign Country)
Home Address Home Phone
% of Ownership in the
Small Business Applicant
Veteran/Gender/Race/Ethnicity data is collected for program reporting purposes only.
Disclosure is voluntary and has no bearing on the credit decision.
Enter Response Below
Veteran 1=Non-Veteran; 2=Veteran; 3=Service-Disabled Veteran; 4=Spouse of Veteran; X=Not Disclosed
Gender M=Male; F=Female; X=Not Disclosed
Race (more than 1
may be selected)
1=American Indian or Alaska Native; 2=Asian; 3=Black or African-American; 4=Native Hawaiian or
Pacific Islander; 5=White; X=Not Disclosed
Ethnicity H=Hispanic or Latino; N=Not Hispanic or Latino; X=Not Disclosed
Unless stated otherwise, if any of the questions below are answered “Yes,” please provide details on a separate sheet.
# Question Yes No
Initial here to confirm your response to question 1
_____
2 Have you been arrested in the last 6 months for any criminal offense?
Initial here to confirm your response to question 2
_____
3
For any criminal offense – other than a minor vehicle violation – have you ever: 1) been convicted; 2) pleaded guilty;
3) pleaded nolo contendere; 4) been placed on pretrial diversion; or 5) been placed on any form of parole or probation
(including probation before judgment)?
Initial here to confirm your response to question 3
_____
If you answer
“Yes” to questions 1 or 2, you must complete a “Statement of Personal History.” You will need to furnish details,
including dates, location, fines, sentences, level of charge (whether misdemeanor or felony), dates of parole/probation, unpaid fines
or penalties, name(s) under which charged, and any other pertinent information.
4
Are you presently suspended, debarred, proposed for debarment, declared ineligible, or voluntarily excluded from
participation in this transaction by any Federal department or agency?
5
If you are a 50% or more owner of the Small Business Applicant, are you more than 60 days delinquent on any
obligation to pay child support arising under an administrative order, court order, repayment agreement between the
holder and a custodial parent, or repayment agreement between the holder and a state agency providing child support
enforcement services.
6 I am a U.S. Citizen OR I have Lawful Permanent Resident status
Registration Number:
I am not a U.S. Citizen or Lawful Permanent Resident
Country of Citizenship:
Initial here to confirm your responses to question 6
_____
7
Do you have any ownership in other businesses which would be defined as an Affiliate in the definition found on page
1? (If “Yes,” attach a listing of all businesses and your ownership percentage or position in the business.)
8 Have you, or any business you controlled, ever filed for bankruptcy protection?
9 Are you, or any business you control, presently involved in any legal action (including divorce)?
10
Have you or any business owned or controlled by you ever obtained a direct or guaranteed loan from EDA or any
other Federal agency or been a guarantor on such a loan? (This includes student loans.)
(a) If you answered “Yes” to Question 10, is any of the financing currently delinquent?
(b) If you answered “Yes” to Question 10, did any of this financing ever default and cause a loss to the
Government?
(If Yes to (a) or (b) above, please provide Lender with a written explanation.)
Business Name:
This form needs to be filled out by all persons owning 20% or more of the operating company and borrowing entity.
SECTION II: Principal Information
Are you presently subject
to an indictment, criminal information, arraignment, or other means by which formal
criminal charges are brought in any jurisdiction?
1