United States of America
SMALL BUSINESS ADMINISTRATION
STATEMENT OF PERSONAL HISTORY
OMB APPROVAL NO.3245-0178
Expiration Date: 07/31/2022
Please Read Carefully and Fully Complete: 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.
SBA District/Disaster Area Office
Amount Applied for (when applicable)
File No. (if known)
1a. Name and Address of Applicant (Firm Name)(Street, City, State, ZIP Code and E-mail)
1b. Personal Statement of: (State name in full, if no middle name, state (NMN), or if initial 2. Give the percentage of ownership in the small Social Security No.
only, indicate initial.) List all former names used, and dates each name was used.
business
Use separate sheet if necessary.
First Middle Last
If applicable, Name and Address of participating lender or surety co.
3. Date of Birth (Month, day, and year)
4. Place of Birth: (City & State or Foreign Country)
5.
U.S. Citizen?
YES NO
INITIALS:
If no, are you a Lawful
Permanent resident alien?
YES
NO
Alien Registration number
If no, country of citzenship:
6.
Present residence address:
From:
To:
Address:
Most recent prior address (omit if over 10 years ago):
From:
To:
Address:
Home Telephone No. (Include Area Code):
Business Telephone No. (Include Area Code):
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, YOU MUST FURNISH DETAILS ON A SEPARATE SHEET. INCLUDE DATES, LOCATION, FINES, SENTENCES,
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
UNTRUTHFUL ANSWER WILL CAUSE YOUR APPLICATION TO BE DENIED AND SUBJECT YOU TO OTHER PENALTIES AS NOTED BELOW.
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
INITIALS:
8. Have you been arrested in the past six months for any criminal offense?
Yes No
INITIALS:
9. 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).
Yes No
INITIALS:
10.
I authorize the Small Business Administration 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
11.
Fingerprints Waived
Date Approving Authority
Fingerprints Required
Date Approving Authority
Date Sent to OPS
12.
Cleared for Processing
Date Approving Authority
13.
Request a Character Evaluation
Date Approving Authority
(Required whenever 7, 8 or 9 are answered "yes" even if cleared for processing.)
SBA 912 (5-2019) SOP 5010 Previous Edition Obsolete
