United States of America
SMALL BUSINESS ADMINISTRATION
STATEMENT OF PERSONAL HISTORY
OMB APPROVAL NO.3245-0178
Expiration Date:
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. For further information, please call
SBA's Answer Desk at 1-800-U-ASK-SBA (1-800-827-5722), or check SBA's
website at www.sba.gov. 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.
Name and Address of Applicant (Firm Name)(Street, City, State, and ZIP Code) SBA District/Disaster Area Office
Amount Applied for (when applicable) File No. (if known)
1. Personal Statement of: (State name in full, if no middle name, state (NMN), or if initial
only, indicate initial.) List all former names used, and dates each name was used.
Use separate sheet if necessary.
First Middle Last
2. Give the percentage of ownership or stock owned
3. Date of Birth (Month, day, and year)
4. Place of Birth: (City & State or Foreign Country)
U.S. Citizen?
YES NO
If non- U.S. citizen provide alien registration number:
Address:
Present residence address:
From:
To:
Home Telephone No. (Include Area Code):
Business Telephone No. (Include Area Code):
Address:
Most recent prior address (omit if over 10 years ago):
From:
To:
PLEASE SEE REVERSE SIDE FOR EXPLANATION REGARDING DISCLOSURE OF INFORMATION AND THE USES OF SUCH INFORMATION.
YOU MUST INITIAL YOUR RESPONSES TO QUESTIONS 5,7,8 AND 9.
IF YOU ANSWER "YES" TO 7, 8, OR 9, FURNISH DETAILS ON A SEPARATE SHEET. INCLUDE DATES, LOCATION, FINES, SENTENCES, WHETHER
MISDEMEANOR OR FELONY, DATES OF PAROLE/PROBATION, UNPAID FINES OR PENALTIES, NAME(S) UNDER WHICH CHARGED, AND ANY
OTHER PERTINENT INFORMATION. AN ARREST OR CONVICTION RECORD WILL NOT NECESSARILY DISQUALIFY YOU; HOWEVER, AN
7. Are you presently subject to an indictment, criminal information, arraignment, or other means by which formal criminal charges are brought in any jurisdiction?
Yes No
8. Have you been arrested in the past six months for any criminal offense?
Yes No
9. For any criminal offense – other than a minor vehicle violation – have you ever: 1) been convicted; 2) plead guilty; 3) plead nolo contendere; 4) been placed on pretrial diversion;
or 5) been placed on any form of parole or probation (including probation before judgment).
Yes No
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 Date
Agency Use Only
Fingerprints Waived
Date Approving Authority
Fingerprints Required
Date Sent to OIG
Date Approving Authority
11.
Cleared for Processing
Request a Character Evaluation
Approving Authority
12.
SBA 912 (2-2013) SOP 5010.4 Previous Edition Obsolete
PLEASE NOTE: The estimated burden for completing this form is 15 minutes per response. 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.
Social Security No.
or to be owned in the small business or the
development company
Name and Address of participating lender or surety co. (when applicable and known)
If No, are you a Lawful
Permanent resident alien:
YES
NO
6.
5.
13.
(Required whenever 7, 8 or 9 are answered "yes" even if cleared for processing.)
Date
Date Approving Authority
INITIALS:
INITIALS:
INITIALS:
INITIALS:
UNTRUTHFUL ANSWER WILL CAUSE YOUR APPLICATION TO BE DENIED AND SUBJECT YOU TO OTHER PENALTIES AS NOTED BELOW.
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.
