SBA Form 912 "Statement of Personal History"

What Is SBA Form 912?

This is a legal form that was released by the U.S. Small Business Administration on May 1, 2019 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2019;
  • The latest available edition released by the U.S. Small Business Administration;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of SBA Form 912 by clicking the link below or browse more documents and templates provided by the U.S. Small Business Administration.

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Download SBA Form 912 "Statement of Personal History"

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OMB APPROVAL NO.3245-0178
Expiration Date: 07/31/2022
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 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 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
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)
5. U.S. Citizen?
If applicable, Name and Address of participating lender or surety co.
YES
NO
INITIALS:
If no, are you a Lawful
NO
YES
Permanent resident alien?
Alien Registration number
If no, country of citzenship:
Most recent prior address (omit if over 10 years ago):
6. Present residence address:
From:
From:
To:
To:
Address:
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
No
INITIALS:
8. Have you been arrested in the past six months for any criminal offense?
Yes
No
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
No
INITIALS:
10. 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 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
Approving Authority
13.
Request a Character Evaluation
Date
Approving Authority
Fingerprints Required
Date
Approving Authority
(Required whenever 7, 8 or 9 are answered "yes" even if cleared for processing.)
Date Sent to OPS
SBA 912 (5-2019) SOP 5010 Previous Edition Obsolete
OMB APPROVAL NO.3245-0178
Expiration Date: 07/31/2022
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 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 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
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)
5. U.S. Citizen?
If applicable, Name and Address of participating lender or surety co.
YES
NO
INITIALS:
If no, are you a Lawful
NO
YES
Permanent resident alien?
Alien Registration number
If no, country of citzenship:
Most recent prior address (omit if over 10 years ago):
6. Present residence address:
From:
From:
To:
To:
Address:
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
No
INITIALS:
8. Have you been arrested in the past six months for any criminal offense?
Yes
No
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
No
INITIALS:
10. 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 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
Approving Authority
13.
Request a Character Evaluation
Date
Approving Authority
Fingerprints Required
Date
Approving Authority
(Required whenever 7, 8 or 9 are answered "yes" even if cleared for processing.)
Date Sent to OPS
SBA 912 (5-2019) SOP 5010 Previous Edition Obsolete
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 3245-
0178. 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 SBAct), 15 USC § 636(a)(1)(B).
Additionally, in making loans pursuant to section 7(a)(6) the SBAct, 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 SBAct 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(5/2019) Previous Edition Obsolete.
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