SBA Business History Statement Business NameIs the Applicant or if the Applicant is structured as an Eligible Passive Company (EPC) and Operating Company (OC), both the EPC and OC, or any Associate of the Applicant presently suspended, debarred, proposed for debarment, declared ineligible, voluntarily excluded from participation in a transaction by any Federal department or agency, or presently involved in any bankruptcy?(Required) Yes No Is the Applicant presently involved in bankruptcy or insolvency?(Required) Yes No Has the Applicant, any Associate of the Applicant, or any business owned by them or any Affiliates (per 13 CFR 121.301(f)), ever obtained a direct or guaranteed loan from SBA, or another Federal agency loan program (including, but not limited to USDA, B&I, FSA, FHA, EDA), or been a guarantor on such a loan?(Required) Yes No Is any of the financing currently delinquent?(Required) Yes No Please provide the Lender with a written explanation of the loan(s) in question.(Required)Does the Applicant have a prior SBA loan?(Required) Yes No Does the Applicant or any business owned or controlled by the Applicant have any outstanding business debt?(Required) Yes No Is the Applicant or any owner of the Applicant an owner of any other business?(Required) Yes No Is the Applicant or any Associate of the Applicant currently incarcerated, serving a sentence of imprisonment imposed upon adjudication of guilty, or is under indictment for a felony or any crime involving or relating to financial misconduct or a false statement?(Required) Yes No Are any of the Applicant's products and/or services exported (directly or indirectly), or is there a plan to begin exporting (directly or indirectly) as a result of this loan?(Required) Yes No Has the Applicant paid or committed to pay a fee to the Lender or a third party to assist in the preparation of the loan application or application materials, or has the Applicant paid or committed to pay a referral agent or broker a fee?(Required) Yes No Are any of the Applicant’s revenues derived from gambling, loan packaging, lending activities, lobbying activities, or from the sale of products or services, or the presentation of any depiction, displays or live performances, of a prurient sexual nature?(Required) Yes No Is the Applicant, any owner of the Applicant, or any business owned by them (Affiliates), presently involved in any legal action (including divorce)?(Required) Yes No The SBA may not provide financial assistance to an applicant where there is any appearance of a conflict of interest with an SBA or other governmental employee.Is any sole proprietor, partner, officer, director, stockholder with a 10 percent or more interest in the Applicant an SBA employee or a Household Member of an SBA employee?(Required) Yes No Is any employee, owner, partner, attorney, agent, owner of stock, officer, director, creditor or debtor of the Applicant a former SBA employee who has been separated from SBA for less than one year prior to the request for financial assistance?(Required) Yes No Is any sole proprietor, general partner, officer, director, or stockholder with a 10 percent or more interest in the Applicant, or a household member of such individual, a member of Congress, or an appointed official or employee of the legislative or judicial branch of the Federal Government?(Required) Yes No Is any sole proprietor, general partner, officer, director, or stockholder with a 10 percent or more interest in the Applicant, or a household member of such individual, a Federal Government employee or Member of the Military having a grade of at least GS-13 or higher (or Military equivalent)?(Required) Yes No Is any sole proprietor, general partner, officer, director, or stockholder with a 10 percent or more interest in the Applicant, or a household member of such individual, a member or employee of a Small Business Advisory Council or a SCORE volunteer?(Required) Yes No Name First Last Signature