Personal Financial Statement Form
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
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
Personal Financial Statement Form PDF
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