Form SBA Form 912 SBA Form 912 Statement of Personal History

OMB APPROVAL NO. 3245-0178
Expiration Date: 12/31/2028

United States of America

Please Read Carefully and Fully Complete: SBA uses Form 912 as one
part of its assessment of program eligibility. Please reference SBA
Regulations and Standard Operating Procedures if you have any
questions about who must submit this form and where to submit it. For
further information, please check SBA's website at www.sba.gov. DO
NOT SEND COMPLETED FORMS TO OMB as this will delay the
processing of your application; send forms to the address provided by
your SBA representative.

SMALL BUSINESS ADMINISTRATION
STATEMENT OF PERSONAL HISTORY

1a. Name and address of Applicant/Borrower/Assumptor (Firm/Business Name; Street, City, State, Zip Code, and Email):

1b. Personal Statement of : (State name in full, if no middle name state NMN, or if initial only indicate initial). List all former names used,
and dates each name was used. Use separate sheet if necessary.

SBA Office:

Loan Number:

2. Give the percentage of ownership in the small business (if applicable):

3. Social Security Number:

4. Date of Birth (month, day, and year)

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

6. Are you a United States Citizen?

If no, please provide an alien registration number: ______________________________

Yes, I am a United States Citizen

I do not have an alien registration number

No, I am not a United States Citizen

INITIALS: ____________________

7. Present Residence Address:

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

From:
To:

From:
To:

Address:

Address:

Home Telephone No. (include area code):
Business Telephone No. (include area code):

8. Are you currently incarcerated, serving a sentence of imprisonment imposed upon adjudication of guilty or under indictment for a felony or any crime
involving or relating to financial misconduct or a false statement?

Yes

No

INITIALS: ____________________

9. In the past year, have you been convicted of a criminal offense committed during and in connection with a riot or civil disorder or other declared disaster?

Yes

No

INITIALS: ____________________

10. Are you currently more than 60 days late on paying any child support obligations?

Yes

INITIALS: ____________________

No

I authorize the Small Business Administration _
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 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.
Signature:

SBA Form 912 (12/2028) Previous Edition Obsolete

Title:

Date:

NOTICES REQUIRED BY LAW

Paperwork Reduction Act (44 U.S.C. Chapter 35)
PLEASE NOTE: The estimated time for completing this request for information, including time for
reviewing instructions, gathering the information needed, and completing and reviewing your
responses, is 15 minutes. You are not required to respond to this collection of information unless it
displays a currently valid OMB Approval Number. The number for this collection of information is 32450178. If you wish to submit comments on the estimated completion time or any other aspect of this
collection of information, direct these comments to: Small Business Administration, Director, Records
Management Division, 409 3rd St., S.W., Washington D.C. 20416 and/or Desk Officer for the Small
Business Administration, Office of Management and Budget, New Executive Office Building, Room
10202, Washington, D.C. 20503.

Privacy Act Statement ( 5 U.S.C. 552a)
Purpose for Collecting Information: SBA is collecting the information on this form, including your social
security number and other personal information to make a character and credit eligibility decision in
connection with you or your company’s application for a loan or other form of SBA assistance.
Submission of the requested information is voluntary; however, because the information is required in
order for SBA to have sufficient information to determine whether to provide you with the requested
assistance, if you do not provide the information, we would be unable to make a final decision on your
application.
Authorities: Under the Privacy Act, 5 U.S.C. § 552a, failure to provide your social security number may
not affect any right, benefit or privilege to which you are entitled. However, disclosures of name and
other personal identifiers are required for a benefit, as SBA requires an individual seeking assistance
from the Agency to provide it with sufficient information to make a character determination. In
determining whether an individual is of good character, SBA considers the person's integrity, candor,
and disposition toward criminal actions. SBA is specifically authorized to verify your criminal history, or
lack thereof, pursuant to section 7(a)(1)(B) of the Small Business Act, (the SB Act), 15 USC § 636(a)(1)
(B). Additionally, in making loans pursuant to section 7(a)(6) the SB Act, 15 USC § 636 (a)(6), SBA is
required to have reasonable assurance that the loan is of sound value and will be repaid or that it is in
the best interest of the Government to grant the assistance requested. Further, for all forms of
assistance, SBA is authorized to make all investigations necessary to ensure that a person has not
engaged in acts that violate or will violate the SB Act or Small Business Investment Act,15 USC §§ 634(b)
(11) and 687b(a). For these purposes, you are asked to voluntarily provide your social security number
to assist SBA when making a character determination to distinguish you from other individuals with the
same or similar name, date of birth or other personal identifier. This request is permitted under EO
9397.
Routine Uses: The information collected may be checked against criminal history indices of the Federal
Bureau of Investigation. When the information collected 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 otherwise involved in
investigation, prosecution, enforcement or prevention of such violations. See, SBA’s Privacy Act System
of Records, at 74 Fed. Reg. 14890 (2009), as amended for other published routine uses for the collected
information.

SBA Form 912 (12/2028) Previous Edition Obsolete