SBIC Management Assessment Questionnaire & License Application; Exhibits to SBIC License App./Mgmt. Assessement Questionnaire

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Notices Required by Law
The following is a brief summary of the laws applicable to this collection of information.

PAPERWORK REDUCTION ACT (44 U.S.C. Chapter 35)
Purpose for Collecting Information: The information requested in this Form 2181 (including, but not limited to, Exhibits A through G and the Managem
Assessment Questionnaire) will be used in connection with an investigation of your experience and character. The scope of this investigation may inclu
with banks, other financial institutions, individuals, business associates, law enforcement offices (including the Federal Bureau of Investigation), and an
will assist SBA in making an adequate appraisal of your general business reputation and character. SBA may also use the information to assist in obtai
bureau reports, including consumer credit reports and scores on the principals of the SBIC applicant, for the purpose of determining whether to appro
principal’s participation in the SBIC program. If information provided to SBA indicates a violation or potential violation of law, whether civil, criminal, or
administrative in nature, SBA may refer it to the appropriate agency, whether Federal, State, local or foreign, charged with responsibility for or otherw
investigation, prosecution, enforcement or prevention of such violations.

Personal information (Privacy Act, 5 U.S.C. 552a)
Any person can request to see or get copies of any personal information that is maintained by SBA. However, requests for information about another
be denied unless SBA has the written permission of the individual to release the information to the requestor or unless the information is subject to di
under the Freedom of Information Act (5 U.S.C. 552). Generally, you are not required to provide your social security number and the failure to provide
security number generally may not affect any right, benefit or privilege to which you are entitled. However, the Debt Collection Improvement Act of 19
7701(c)(1)) requires a Federal agency to obtain the taxpayer identification number (TIN) from each person doing business with that agency.). Therefore
mandatory that you furnish your TIN to the SBA as part of your licensing application. Additionally, disclosure of your name and other personal informa
requested is mandatory. SBA is required under Section 301(c)(3) of the Small Business Investment Act, 15 U.S.C. 681(c)(3), to consider the general busin
reputation of certain key individuals in order to make a determination about whether each individual has the business experience and character neces
participate in the SBIC program. Your social security number and other personal identifiers assist SBA in making these determinations required by law
provide this information, SBA will be unable to reach a favorable determination concerning your participation in the SBIC program.

Freedom of Information Act (U.S.C. 552)
This law provides, with some exceptions, that we must make records or portions of records contained in our files available to persons requesting them
generally includes aggregate statistical information on the SBIC program and other information such as names of licensed SBICs and names of comp
have been financed by SBICs. We do not routinely make available to third parties your proprietary data or information that would cause competitive h
constitute a clearly unwarranted invasion of personal privacy. We note that Exemptions, 4, 6 and 8 of the Freedom of Information Act (FOIA) allow SBA
financial data on individual companies. To request information under FOIA, you must send the request to the SBA office maintaining the records requ
Chief, FOI/PA Office, 409 3rd Street, SW, Washington, DC 20416, or by e-mail to [email protected], and identify it as a Freedom of Information Act (FOIA) re
request must describe the specific records you want

xhibits A through G and the Management
e scope of this investigation may include contact
ederal Bureau of Investigation), and any others that
use the information to assist in obtaining credit
pose of determining whether to approve a
ation of law, whether civil, criminal, or
rged with responsibility for or otherwise involved in

quests for information about another individual may
unless the information is subject to disclosure
ity number and the failure to provide your social
Debt Collection Improvement Act of 1996 (31 U.S.C.
business with that agency.). Therefore, it is
our name and other personal information
681(c)(3), to consider the general business
siness experience and character necessary to
these determinations required by law. If you do not
the SBIC program.

s available to persons requesting them. This
of licensed SBICs and names of companies that
mation that would cause competitive harm or would
m of Information Act (FOIA) allow SBA to withhold
A office maintaining the records requested or the
Freedom of Information Act (FOIA) request. The

Individual Legal Questionnaire

As of Date: MM/DD/YYYY
You are required to submit this exhibit for each principal. Answer all of the following questions. If the answer to any question is “yes”, furnish
provide any necessary attachments. Include all pertinent information, including, name(s) under which charged, dates, locations, titles of pro
fines and penalties (paid and unpaid), sentences, type of offense (misdemeanor or felony), dates of parole/probation, names of mediators, a
dispute resolution professionals, and relevant documents. For the purposes of this exhibit, a “substantial ownership interest” in an organizati
interest, direct or indirect, of 20% or more in equity interests, voting interests, or profit interests. The term “senior management” generally
participation in budget or investment decisions, including participation as a member of the board of directors. If you have questions about w
have been considered part of senior management, discuss the issue with SBA Office of Investment and Innovation. This exhibit must be signe
either a MAQ application and/or a Final License application. Any changes in the responses between the MAQ application and the Final Licens
and explained.
Name of Applicant:

Name of Principal:

1 Have you ever been charged with or arrested for any criminal offense other than a minor motor vehicle violation (including offenses that
have been dismissed, discharged, expunged, or not prosecuted or settled through plea deal or other similar process)?

2 Have you ever been convicted, placed on pretrial diversion, entered into a plea deal or other similar process, or placed on any form of pro
(including adjudication withheld pending probation) for any criminal offense other than a minor motor vehicle violation?

3 Have you ever ever (a) been found civilly liable, (b) entered into a settlement through mediation, arbitration or other alternative dispute re

process or (c) been permanently or temporarily enjoined by a court or other regulatory body by reason of any act or practice involving fra
trust?

4 Has any organization either while you were a member of senior management or when you had a substantial ownership interest, ever bee

charged with, entered into a plea deal for, or convicted of any criminal offense involving fraud, breach of fiduciary duty or breach of trust?

5 Has any organization, either while you were a member of senior management or when you had a substantial ownership interest, ever be

convicted or permanently or temporarily enjoined by a court, or entered into a settlement agreement for by mediation, arbitration or oth
dispute resolution process by reason of any act or practice involving fraud, breach of fiduciary duty or breach of trust?

6

Are you now the subject of any investigation or disciplinary hearing or proceeding by a governmental agency, regulatory body, or profess

7 Have you ever been the subject of any investigation or disciplinary hearing or proceeding by a governmental agency, regulatory body, or
association?

8 Are you now or have you ever been the subject of any suspension, debarment, or any other regulatory enforcement, or any other regulat

enforcement action by a State or Federal agency based on fraud, lack of business integrity, or violation or noncompliance with regulation
governmental requirements?

9 Has any organization, either while you were a member of senior management or when you had a substantial ownership interest, ever be
of any investigation or disciplinary hearing or proceeding by a governmental agency, regulatory body, or professional association?

10 Is any organization of which you are currently a member of senior management, or in which you have a substantial ownership interest, n
of any investigation or disciplinary proceeding by a governmental agency, regulatory body, or professional association?

11 Have you ever entered into an agreement concerning (through mediation, arbitration, other alternative dispute resolution process or sim

otherwise consented to any order or decree by a court, governmental agency or regulatory body in connection with, any federal or state s

12 Has any organization, either while you were a member of senior management or when you had a substantial ownership interest, ever en

agreement concerning (through mediation, arbitration, other alternative dispute resolution process or similar process), or otherwise cons
order or decree by a court, governmental agency or regulatory body in connection with any federal or state securities law?

13 During the past 10 years, have you been a named defendant in any civil legal action involving commercial disputes or creditor's claims (in

limited to debt collection lawsuit, foreclosure, receivership, and involuntary liquidation) of greater than $500,000 for corporate liabilities o
$100,000 for personal liabilities?

If “yes”, did the subject matter involve your personal conduct or fall within your area of responsibility?
If the answer is “yes”, were you active in settlement negotiations or arbitration?

14 Have you, as a result of your role as a member of senior management or as a member of the board of directors of any entity been a name
any civil legal action involving (i) shareholder litigation, (ii) fraud or misrepresentation, or (iii) breach of fiduciary duty?

If “yes”, did the subject matter involve your personal conduct or fall within your area of responsibility?
If the answer is “yes”, were you active in settlement negotiations or arbitration?

15 Have you, in your individual capacity, ever been a named defendant in any civil legal action involving (i) shareholder litigation, (ii) fraud or
misrepresentation, or (iii) breach of fiduciary duty?

16 During the past 10 years, have you filed voluntarily, or had filed against you involuntarily, a bankruptcy petition?

17 During the past 10 years, has any organization, either while you were a member of senior management or when you had a substantial ow
interest, filed voluntarily, or had filed against such organization involuntarily, a bankruptcy petition?

18 Have you ever failed to pay when due any debt or obligation, including any amounts in dispute, to the Federal government or any state g
guaranteed by the Federal government or any state government (including but not limited to taxes, business loans, student loans, etc.)?

19 Has any organization, either while you were a member of senior management or when you had a substantial ownership interest, ever fai

due any debt or obligation, including any amounts in dispute, to the Federal government or any state government, or guaranteed by the
government or any state government (including but not limited to taxes, business loans, educational loans, etc.)?

CERTIFICATION AND AUTHORIZATION TO RELEASE INFORMATION

I certify that all of the information I have provided on this Individual Legal Questionnaire and any other information I have submitted in c
this Individual Legal Questionnaire is true, correct and complete to the best of my knowledge. I understand that knowingly making a fals
violation of Federal law and could result in criminal prosecution under 18 USC §§ 287, 371, 1001, 1006, and 1014, including fines of up to $
up to 30 years imprisonment, 15 USC §§ 645 and 687(f), civil penalties under 31 U.S.C. § 3729, government-wide debarment or suspension
suspension, or revocation of a Small Business Investment Company license.

In connection with an application for an SBIC license, or operation of an SBIC, I hereby authorize the U.S. Small Business Administration (“
agents to make inquiries, including obtaining a consumer report from a consumer reporting agency, to determine by person credit stand

I have read the “Notices Required by Law” and I authorize the U.S. Small Business Administration Office of Inspector General to request cr
information about me from criminal justice agencies for the purpose of determining my eligibility for the Small Business Investment Com

20 Printed Name
21 Title
22 Signature
23 Date

swer to any question is “yes”, furnish complete details and
harged, dates, locations, titles of proceedings, docket numbers,
le/probation, names of mediators, arbitrators or other alternative
l ownership interest” in an organization is considered to be an
erm “senior management” generally refers to meaningful
ctors. If you have questions about whether or not you would
nnovation. This exhibit must be signed when submitted as part of
MAQ application and the Final License application should be noted

[First]

[Last]

le violation (including offenses that
similar process)?

rocess, or placed on any form of probation
r vehicle violation?

ration or other alternative dispute resolution
n of any act or practice involving fraud or breach of

stantial ownership interest, ever been indicted for,
of fiduciary duty or breach of trust?

stantial ownership interest, ever been found liable,
for by mediation, arbitration or other alternative
breach of trust?

agency, regulatory body, or professional association?

mental agency, regulatory body, or professional

y enforcement, or any other regulatory
n or noncompliance with regulations or other

bstantial ownership interest, ever been the subject
, or professional association?

a substantial ownership interest, now the subject
ional association?

ve dispute resolution process or similar process), or
onnection with, any federal or state securities law?

bstantial ownership interest, ever entered into an
r similar process), or otherwise consented to any
state securities law?

rcial disputes or creditor's claims (including but not
n $500,000 for corporate liabilities or greater than

directors of any entity been a named defendant in
f fiduciary duty?

i) shareholder litigation, (ii) fraud or

nt or when you had a substantial ownership

Federal government or any state government, or
usiness loans, student loans, etc.)?

bstantial ownership interest, ever failed to pay when
government, or guaranteed by the Federal
oans, etc.)?

er information I have submitted in connection with
rstand that knowingly making a false statement is a
, and 1014, including fines of up to $1 million and
ment-wide debarment or suspension, and denial,

U.S. Small Business Administration (“SBA”) and its
to determine by person credit standing.

e of Inspector General to request criminal record
the Small Business Investment Company program.

Identified Parties

As of Date: MM/DD/YYYY
In the table below, please identify:
1) All officers and directors of a corporate SBIC, general partners of a limited partnership SBIC, or managers of an LLC SBIC. (Note that if
manager of an LLC SBIC is an entity, then all of the managers of the entity must be listed.)
2) Individuals or entities that exercise "Control" or who are “Control Persons” (both as defined in 13 CFR 107.50) of the Licensee, the Ge
greater than fifty percent (50%) or more of the unfunded and funded commitments to the Licensee.
3) All investment committee members and any individual whose role is highly influential (SBA liaison, officers and employees of the appl
management responsibility and/or signing authority for the applicant).
4) The three ranking managers or officers of any entity described in (1) or (2) above.
Name of Applicant:

Individual or Entity Name

to add rows add above row 18

Name of Principal:

Code (Select from one of
the four categories
above)

Role in the SBIC

ers of an LLC SBIC. (Note that if the general partner of a limited partnership SBIC or the
107.50) of the Licensee, the General Partner of the Licensee, including limited partners with

fficers and employees of the applicant’s investment adviser/manager with day-to-day

[First]

the SBIC

[Last]

Statement of Personal History

As of Date: MM/DD/YYYY
Each principal and individual identified on the "Identified Parties" tab is required to submit and execute this Statement of Personal History. A
answer to any question is “yes”, furnish complete details and provide any necessary attachments. Include all pertinent information, includin
locations, titles of proceedings, docket numbers, fines and penalties (paid and unpaid), sentences, type of offense (misdemeanor or felony),
mediators, arbitrators or other alternative dispute resolution professionals, and relevant documents.
Name of Applicant:

[Name Here]

Name of Principal:

SBIC

Applicant or Licensee Name

[Name Here]

Address: Street, City, State, Zip Code
Telephone:

[Street Address]
(###) ###-####

First Name in Full

[City]

Email

Middle Name(s) in Full (If “none”, so
state)

List All Former Name(s) and Any Other Current Names Used (If “none”, so state)

Last Name

From (Date)

MM/DD/YYYY

List current and any former or other
social security numbers (SSNs) used
and names associated with these
numbers. (If no other SSNs used, so
state.)

Date of Birth (Month, Day, Year)

MM/DD/YYY

Place of Birth (City, State, Country)
Citizen of U.S.? (Y/N)
If a U.S.
citizen

Native Born
(Y/N)?

If naturalized, date, city, state and the
naturalization or citizenship certificate
number
If you are not a citizen of the U.S., are
you a permanent resident alien?

MM/DD/YYYY

City, State

If “yes” to "permanent resident alien",
provide the date you entered the U.S.,
the location (city and state) and your
alien registration number

MM/DD/YYYY

City, State

Starting with your present address, list all residence addresses for the last ten years.

From (Date)

To (Date)

Address

MM/DD/YYYY

MM/DD/YYYY

Street, City, State, Zip

1 Have you ever been charged with or arrested for any criminal offense other than a minor motor vehicle violation (including offenses that
dismissed, discharged, expunged, or not prosecuted or settled through plea deal or other similar process)?

2 Have you ever been convicted, placed on pretrial diversion, entered into a plea deal or other similar process, or placed on any form of pro
adjudication withheld pending probation) for any criminal offense other than a minor motor vehicle violation?

3 Have you ever ever (a) been found civilly liable, (b) entered into a settlement through mediation, arbitration or other alternative dispute re
permanently or temporarily enjoined by a court or other regulatory body by reason of any act or practice involving fraud or breach of tru

CERTIFICATION AND AUTHORIZATION TO RELEASE INFORMATION

I certify that all of the information I have provided on this Statement of Personal History and any other information I have submitted in co
of Personal History is true, correct and complete to the best of my knowledge. I understand that knowingly making a false statement is a
could result in criminal prosecution under 18 USC §§ 287, 371, 1001, 1006, and 1014, including fines of up to $1 million and up to 30 years
645 and 687(f), civil penalties under 31 U.S.C. § 3729, government-wide debarment or suspension, and denial, suspension, or revocation o
Investment Company license.

I have read the “Notices Required by Law” and I authorize the U.S. Small Business Administration Office of Inspector General to request cr
about me from criminal justice agencies for the purpose of determining my eligibility for the Small Business Investment Company progra

Printed Name
Title
Signature
Date

his Statement of Personal History. Answer all of the following questions. If the
de all pertinent information, including, name(s) under which charged, dates,
of offense (misdemeanor or felony), dates of parole/probation, names of
Name of Principal:

[First]

[Last]

[State XX]

[Zip Code]

[Name Here]
[City]

Last Name

From (Date)

To (Date)

MM/DD/YYYY

MM/DD/YYYY

YY

he last ten years.

Address
Street, City, State, Zip

e violation (including offenses that have been
ess)?

ocess, or placed on any form of probation (including
olation?

ation or other alternative dispute resolution process or (c) been
ice involving fraud or breach of trust?

r information I have submitted in connection with this Statement
wingly making a false statement is a violation of Federal law and
up to $1 million and up to 30 years imprisonment, 15 USC §§
denial, suspension, or revocation of a Small Business

e of Inspector General to request criminal record information
siness Investment Company program.