Fillable Usa Sba Form 912 - Small Business Administration Statement Of Personal History printable pdf download

OMB APPROVAL NO.3245-0178

Expiration Date: 05/31/2019

SBA uses Form 912 as one part

Please Read Carefully and Fully Complete:

of its assessment of program eligibility. Please reference SBA Regulations and

United States of America

Standard Operating Procedures if you have any questions about who must

SMALL BUSINESS ADMINISTRATION

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

STATEMENT OF PERSONAL HISTORY

website at 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.

1a. Name and Address of Applicant (Firm Name)(Street, City, State, ZIP Code and E-mail) SBA District/Disaster Area Office

FARGO, ND

File No. (if known)

Amount Applied for (when applicable)

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

3. Date of Birth (Month, day, and year)

4. Place of Birth: (City & State or Foreign Country)

If applicable, Name and Address of participating lender or surety co.

U.S. Citizen?

YES

INITIALS:

LAKE AGASSIZ CDC

If no, are you a Lawful

YES

Permanent resident alien?

417 MAIN AVE, FARGO, ND 58103

Alien Registration number

If no, country of citzenship:

Most recent prior address (omit if over 10 years ago):

Present residence address:

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

INITIALS:

8. Have you been arrested in the past six months for any criminal offense?

Yes

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

INITIALS:

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

12.

Cleared for Processing

Date

Approving Authority

11.

Fingerprints Waived

Date