Personal Financial Statement (Page 3 of 4) in pdf

Section 5. Other Personal Property and Other Assets. (Describe, and, if any is pledged as security, state name and address of lien

holder, amount of lien, terms of payment and, if delinquent, describe delinquency.)

Section 6. Unpaid Taxes. (Describe in detail as to type, to whom payable, when due, amount, and to what property, if any, a tax

lien attaches.)

Section 7. Other Liabilities. (Describe in detail.)

Section 8. Life Insurance Held. (Give face amount and “Current” cash surrender value of policies – name of insurance company a

Beneficiaries.)

I authorize the SBA to make inquiries as necessary to verify the accuracy of the statements. CERTIFICATION: (to be completed by

person submitting the information requested on this form)

By signing this form, I certify under penalty of criminal prosecution that all information on this form and any additional supporting

information submitted with this form is true and complete to the best of my knowledge. I understand that SBA will rely on this

information when making decisions regarding an application for participation in the SBA 8(a) Business Development (BD) Program.

Signature ________________________________________

Date

____________________

Print Name _______________________________________

Social Security No.

____________________

Signature ________________________________________

Date

____________________

Print Name _______________________________________

Social Security No.

____________________

NOTICE TO APPLICANTS OR PARTICIPANTS IN THE 8(a) BD PROGRAM: CRIMINAL PENALTIES AND ADMINISTRATIVE

REMEDIES FOR FALSE STATEMENTS

Any person who misrepresents a business concern’s status as an 8(a) BD Program participant or SDB concern, or makes any other

false statement in order to influence the 8(a) certification or other review process in any way(e.g., annual review, eligibility review),

shall be: (1) subject to fines and imprisonment of up to 5 years, or both, as stated in Title 18 U.S.C. § 1001; (2) subject to fines of up

to $500,000 or imprisonment of up to 10 years, or both, as stated in Title 15 U.S.C. § 645; (3) subject to treble damages and civil

penalties under the False Claims Act, 31 U.S..C 3729; (4) subject to administrative remedies, including suspension and debarment;

and (5) ineligible for participation in programs conducted under the authority of the Small Business Act.

The estimated average burden hours for the completion of this form is 1.5 hours per response. If you have

PLEASE NOTE:

questions or comments concerning this estimate or any other aspect of this information, please contact Chief,

Administrative Branch, U.S. Small Business Administration, Washington, D.C. 20416, and Clearance officer,

paper Reduction Project (3245-0188), Office of Management and Budget, Washington, D.C. 20503. PLEASE

DO NOT SEND FORMS TO OMB.

SBA Form 413 (8a) (09-14) Previous Editions Obsolete

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Personal Financial Statement Page 3