Fillable Printable Personal Financial Statement Form
Fillable Printable Personal Financial Statement Form
Personal Financial Statement Form
OMB APPROVAL NO.: 3245-0188
EXPIRATION DATE: 01/31/2018
PERSONAL FINANCIAL STATEMENT
7(a) / 504 LOANS AND SURETY BONDS
U.S . SM ALL BUSI NESS ADMI NIS TRATION As of ________ ________, ________
SBA uses the information required by this Form 413 as one of a number of data sources in analyzing the repayment ability and creditworthiness of an application for an
SBA guaranteed 7(a) or 504 loan or a guaranteed surety.
Complete this form for: (1) each proprietor; (2) general partner; (3) managing member of a limited liability company (LLC); (4) each owner of 20% or more of the equity of
the Applicant (including the assets of the owner’s spouse and any minor children); and (5) any person providing a guaranty on the loan
Return completed form to:
For 7(a) loans: the lender processing the application for SBA guaranty
For 504 loans: the Certified Development Company (CDC) processing the application for SBA guaranty
For Surety Bonds: the Surety Company or Agent processing the application for surety bond guaranty
Description of Other Income in Section 1.
*Alimony or child support payments should not be disclosed in “Other Income” unless it is desired to have such payments counted toward total income.
SBA Form 413 (7a/504/SBG) (09-14) P r evi ous Edi tions Obsolete Pag e 1
Name Business P hone
Home Address Home Phone
City, State, & Zip Code
Business Name of Applicant
ASSETS (Omit Cents) LIABILITIES (Omit Cents)
Cash on Hand & in banks…………………………$ ________________
Savings Accounts…………………………………..$ ________________
IRA or Other Retirement Account………………...$ ________________
(Describe in Section 5)
Accounts & Notes Receivable…………………….$ ________________
(Describe in Section 5)
Life Insurance – Cash Surrender Value Only……$ ________________
(Describe in Section 8)
Stocks and Bonds…………………………………..$ ________________
(Describe in Section 3)
Real Estate…………………………………………..$ ________________
(Describe in Section 4)
Automobiles…………………………………………$ ________________
(Describe in Section 5, and include
Year/Make/Model)
Other Personal Property……………………………$ ________________
(Describe in Section 5)
Other Assets………………………………………….$ _______________
(Describe in Section 5)
Total $ ________________
Accounts Payable……………………………$ ______________
Notes Payable to Banks and Others……….$ ______________
(Describe in Section 2)
Installment Account (Auto)…………………..$ ______________
Mo. Payments $ ___________
Installment Account (Other)………………....$ ______________
Mo. Payments $ ___________
Loan(s) Against Life Insurance……………...$ ______________
Mortgages on Real Estate…………………...$ ______________
(Describe in Section 4)
Unpaid Taxes………………………………….$ _____________
(Describe in Section 6)
Other Liabilities………………………………..$ _____________
(Describe in Section 7)
Total Liabilities………………………………....$ _____________
Net Worth……………………………………….$ _____________
Total $ _____________
*Must equal total in assets column.
Section 1. Sourc e of Income. Conti ngent Liabilities
Salary………………………………………………….$ ________________
Net Investment Income……………………………...$ ________________
Real Estate Income………………………………….$ ________________
Other Income (Describe below)*…………………...$ ________________
As Endorser or Co-Maker…………………….$ _____________
Legal Claims & Judgments…………………..$ _____________
Provision for Federal Income Tax…………....$_____________
Other Special Debt…………………………….$ _____________
Section 2. Notes Payable to Banks and Others. (Use attachments if necessary. Each attachment must be identified as part of this statement and signed.)
Names and Addresses of
Noteholder(s)
Original
Balance
Current
Balance
Payment
Amount
Frequency
(monthly, etc.)
How Secured or Endorsed
Type of Collateral
Section 3. Stocks and Bond s. (Use attachments if necessary. Each attachment must be identified as part of this statement and signed.)
Number of Shares Name of Securities Cost
Market Value
Quotation/Exchange
Date of
Quotation/Exchange
Total Value
Section 4. Real Estate Owned. (List each parcel separately. Use attachment if necessary. Each attachment must be identified as a part of this statement
and signed.)
Prope rt y A Prope rty B Prope rty C
Type of Real Estate (e.g.
Primary Residence, Other
Residence, Rental Property,
Land, etc.)
Address
Date Purchased
Original Cost
Present Market Value
Name & Address of
Mortgage Holder
Mortgage Account Number
Mortgage Balance
Amount of Payment per
Month/Year
Status of Mortgage
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.)
SBA Form 413 (7a/504/SBG) (09-14) P r evi ous Edi tions Obsolete P age 2
Section 8. Life Insurance Held. (Give face amount and cash surrender value of policies – name of insurance company and
Beneficiaries.)
I authorize the SBA/Lender/Surety Company to make inquiries as necessary to verify the accuracy of the statements made and to
determine my creditworthiness.
CERTIFICATION: (to be completed by each 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 or its participating
Lenders or Certified Development Companies or Surety Companies will rely on this information when making decisions regarding an
application for a loan or a surety bond. I further certify that I have read the attached statements required by law and executive order.
Signature ________________________________________ Date ____________________
Print Name _______________________________________ Social Security No. ____________________
Signature ________________________________________ Date ____________________
Print Name _______________________________________ Social Security No. ____________________
NOTICE TO LOAN AND SURETY BOND APPLICANTS: CRIMINAL PENALITIES AND ADM INISTRATIVE REMEDIES 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 or surety bond application. A false statement is punishable under 18 U.S.C. §§ 1001 and 3571 by
imprisonment of not more than five years and/or a fine of up to $250,000; under 15 U.S.C. § 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, a false statement is punishable
under 18 U.S.C. § 1014 by imprisonment of not more than thirty years and/or a fine of not more than $1,000,000. Additionally, false
statements can lead to treble damages and civil penalties under the False Claims Act, 31 U.S.C. § 3729, and other administrative
remedies including suspension and debarment.
PLEASE NOTE: The estimated average burden hours for the completion of this form is 1.5 hours per response. If you have 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 (7a/504/SBG) (09-14) Previous Edit ions Obsolete Page 3
PLEASE READ, DETACH, AND RETAIN FOR YOUR RECORDS
STAT EM E NTS REQUIRED BY LAW AND EXECUT I VE ORDER
SBA is re quired to wit hhold or limit financial assistance, to impose specia l c ondition s on approved loans, to provide
special notices to applicants or borrowers and to require special reports and data from borrowers in order to comply with
legislation passed by the Congress and Executive Orders issued by the President and by the provisions of vario us inter-
agency agreeme nts. SBA has issued regulations and pro ced ures that imple ment these la ws and executive orders. These are
contained in Parts 112, 113, and 117 of Title 13 of the Code of Federal Regulations and in Standard Operating
Procedures.
Privacy Act (5 U.S.C. 552a)
Any perso n can request to see or get copies of any personal information that SBA has in his or her file when that file is
retrieved by individual identifiers such as name or social security numbers. Requests for information about another party
may be denied unless SBA has the written permission of the individual to release the information to the requestor or
unless the informat i on is subject to disclosure under the Freedom of Information Act.
Under the provisions o f the Privacy Act, you are not required to provide your social security number. Failure to provide
your so c ia l security number m ay not affect any ri ght, benefit or privilege to which you ar e entitled . Disclosures of name
and other personal identifiers ar e, however, required for a benefit, as SB A requires an individual seeking assistance fro m
SBA to provide it with sufficient information for it to make a character determination. In determining whether an
individ ual is of good character, SBA considers the person’s integri ty, cando r , and disposition towa r d criminal ac tions.
Additionall y, SBA i s sp e c ificall y au t hor ized to verif y yo ur criminal hist ory, o r la ck thereof, pur s uant to section
7(a)(1)(B), 15 USC Section 636(a)(1)(B) of the Small Busines s Act ( the Act). Further, for all forms of assistance, SBA is
authorized to make all inve stigations necessary to ensure that a person has not enga ged in acts that violate or will violate
the Act or the Small Busi ness Investment Act, 15 USC Sections 634(b)(11) and 687(b)(a), respectively. For these
purposes, you are asked to vol untarily provide your social security number to assist SBA in making a character
dete rminati on and to disting uish yo u from other individuals with the same or similar na me or other personal identifier.
The Privacy Act a uthorizes SBA to make certain “routine uses” of infor mation protected by that Act . One such routi ne
use is t he disclosure o f information maintained in SBA’s investigative files s ystem of recor ds when this information
indicates a violation or potenti a l vio la tion of law, whether civil, criminal, or a dministrative in nature . Specifica lly, SBA
may refer the information to the approp riate agency, whether Federal, State, local or foreign, charged with responsibility
for, or otherwise involved in investigatio n, pro secution, enfo rcement or preventi on of such vio lati ons. Ano ther ro uti ne use
is disclo sure to other Federal agencies conducti ng b ackgrou nd chec ks ; only to the extent the info rmation is relevant to t he
requesting agencies' fu nction. See, 74 F.R. 14890 (2009), and as amended fro m time to time for additional background
and other ro utine uses.
Right to Financial Privacy Act of 1978 (12 U.S.C. 3401) -- T his is notice to you as req uire d by the Right to Financial
Privacy Act of 1978, of SBA's access rights to financial re c ords held b y financial institutions that are o r have been doi ng
bus i ness wit h yo u or your bu s iness , inc luding any financial inst it utions partic ipating i n a loan or loan guaranty. The law
provides that SBA shall have a right of access to your financia l r e c ords in co nnection with its co nsidera tion or
administration of assistance to you in the form of a Governm ent guaranteed loan. SBA is required to provide a certificate
of its compliance wit h the Act to a financial institutio n in connection with it s first request for access to yo ur fi nancial
records, after which no further certification is required for subsequent accesses. The law also pr o vides that SB A's access
ri ghts conti nue for t he te rm of any approved loan guara nty agreeme nt. No f urther notice to you of SBA's access rights is
requi red d uring the term of an y suc h agreement. The law also authorizes S BA to transfer to anot her Government authority
any financial record s included in a application for a loan, or concerning an approved loan or loan guarantee, as necessary
to process, service or foreclose on a loan guaranty or collect on a defaulted loan guara nty.
Freedom of Information Act (5 U.S.C. 552)
This law provides, wit h some e xceptions, t hat SBA must sup ply in formation reflected in agency files and records to a
person requesting it. Information about appro ved loans that will be automatically released includes, among ot her t hings,
statistics on our loan pr ogra ms (individual borr owe rs are not identified in the statistics) a nd other informati on s uch as the
names of the borrowers (and their officers, directors, stockholders or partners), the collateral pledged to secure the loan,
the amoun t of the loan, its purpose in general terms and the maturity. Proprietary data on a borrower would not routinely
be made available to third parties. All requests under this Act are to b e addressed to the nearest SBA o ffice and be
identified as a Freedom of Info r mation request.
Flood Disaster Protection Act (42 U.S.C. 4011) -- Regulations have been issued by the Federal Insurance
Admi nistration (FIA) and by SBA i mp lementing this Act a nd its amend men ts. These re gulations p rohibit SBA fro m
making certain loans in an FIA designated floodplain unless Federal Flood insurance is purchased as a condition of the
loan. F a ilure to main ta in the r e quired level of flood insurance make s the applicant ineligible for any financial assistance
from SBA, including disaster assistance.
SBA Form 413 (7a/504/SBG) (09-14) Previous Edit ions Obsolete Page 4
Exec utive O rders -- Floodplain Management and Wetland Protection (42 F.R. 26951 and 42 F.R. 26961) – SBA
disco ura ges settlement in or d e velop ment of a flood plain or a wetland. This state ment is to no tif y all SBA loan applicants
that such actions are hazardous to both life and property and should be avoided. The additional cost of flood preventive
construction must be considered in addition to the possible loss of all assets and investments due to a future flood.
Occupational Safety and Health Act (15 U.S.C. 651 et seq.) -- T his legislation authorizes the Occupational Safety and
Health Administra tion in the Dep a r tment of Labor to r e quire businesses to modif y faciliti es and proced ures to protect
employees or pay penalty fees. B usinesses can be forced to cease oper ations or be prevented from starting operations i n a
new facility. T herefore, SBA may requ ire additional information from a n applicant to deter mine whet her the business will
be in compliance with OSHA r e gulat ions and allowed to o perate its facility after the loan is app r oved and disbursed.
Signing t his form as an appl icant i s c e rtification that the OSHA requireme nts t hat a pply to the applicant b usiness have
been determined and that the applicant, to the best of its knowledge, is in co mpliance. Further more, applicant certifies that
it will remai n in compliance during the life of the loan.
Civil Rights Legislation -- All businesses receiving SBA financial assistance must agree not to discrimi nate in any
business pr actice, including employment practices and services to the public on the basis of categories cited in 13 C.F.R.,
Parts 112, 113, and 117 of SBA Regul ations. This inc ludes maki ng thei r go od s and s ervi ces available to ha ndicapped
client s o r customer s. A ll business borrowers will be required to display the "Equal Employment Opportunity Poste r"
prescribed by SBA.
Equal Credit Opportunity Act (15 U.S.C. 1691) -- The Federal Equal Credit Opportunity Act prohibits cr e ditors from
discr iminating against credit applicants on the b a sis o f rac e , color, religion, national or igin, sex, marital status or age
(provided the applicant has the capacity to e nter into a bindi ng contract); because all or part of the applicant's inco me
derives fro m any public assistance progra m, or because the app licant has in good faith e xe r cised any right u nder the
Consumer Credit Pro te c tion Act.
Exec utive O rder 11 7 38 -- Environmental Protection (38 F.R. 251621) -- The Executive Order charges SBA wit h
administering its loan programs in a manner that will result in effective enforceme nt of the Clean Air Act, the Federal
Water Poll utio n Act and o ther environment p rotection legisla tion.
Debt Collection Act of 1982, Deficit Reduction Act of 1984 (31 U.S.C. 3701 et seq. and other titles) -- These laws
require SBA to col lec t aggressively an y l oan payments whi ch become delinquent. S BA m us t obtai n yo ur taxpayer
identi fication nu mber when you apply for a loan. If yo u receive a loan, and do not make payments as they come due, SBA
may take one or more of t he f ollowing actio ns: (1) report the statu s of your loan(s) to credit bureaus, (2) hire a collection
agency t o coll ect your loan, ( 3) offset your i ncome tax refund or other amounts due to you fro m the Federal Government,
(4) suspend or debar you or your company fro m doing business with the Federal Government, (5) refer your loan to the
Department of Justice or other a ttorne ys for litigation, or (6) foreclose on colla te r a l or take other a c tion permitted in the
loan instr uments.
Immigration Reform and Control Act of 1986 (Pub. L. 99-603) -- If yo u are an a l ien who was in this country illegally
since before January 1, 1982, you may have been granted lawful temporary resident status by the United States
Immigr ation and N a turalization Service pursuant to the Immigratio n Reform and Control Act of 1986. Fo r five year s fro m
the date you are granted such status, you are not eligible for financial assistance from the SBA in the form o f a loan
guarant y under S ection 7(a) of the Small B usines s Act u nless you are di s abled or a Cuban or Haitian ent rant. Whe n yo u
sign this document, you are making the certification that the I mmigration Reform and Control Act of 1986 does not apply
to yo u, or if it does apply, more than fi ve years have elapsed since you have been granted lawful temporar y resident status
pursuant t o such 1986 legislation.
Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4821 et seq.)
Borro wers using SBA funds for the construction or rehabilitation of a residential structure are prohibited from using lead-
based paint (as defined in SBA regulations) on all interior surfaces, whether accessible or not, and exterior surfaces, such
as stairs, decks, porches, railings, windo ws and doors, which are readily accessible to children under 7 years of age. A
"residential structure" is any home, apartment, hotel, motel, orphanage, boarding school, dormitory, day care center,
extended care facility, college or other school housing, hospital, group practice or commun ity facility and all other
residential o r institutional structure s where persons reside.
Exec utive Order 125 49 , Debarment and Suspens ion 2 CFR 2700
1. The borrower or contractor cer tifies, by sub mis sio n o f its application for an SBA loan or bond guarantee, that neithe r
it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from particip a tion in this transaction by any Federal department or agency.
2. Where the prospective lower tier participant is unable to cer tify to any of the statements in t his cer tification, such
prospective p a rticipants s hall attach an explanation to the applica tion.
SBA Form 413 (7a/504/SBG) (09-14) P r evi ous Edi tions Obsolete Page 5
