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SBA Form 4 (9-09) Previous Edition Obsolete Page 1

OMB Approval No. 3245-0016 Expiration Date: 11/30/2012

U. S. Small Business Administration

APPLICATION FOR BUSINESS LOAN

Individual Full Address

Name of Applicant Business Tax I.D. No. or SSN

Full Street Address of Business Tel. No. (inc. Area Code)

City County State Zip

Type of Business Date Business Established

Bank of Business Account and Address

Number of Employees (including subsidiaries and affiliates)

At Time of Application _______

If Loan is Approved _______

Subsidiaries or Affiliates _______ (Separate for above)

Use of Proceeds: (Enter Gross Dollar Amounts Rounded to the Nearest Hundreds)

Loan Requested Loan Request

Land Acquisition Pay off SBA Loan

New Construction/ Expansion Repair

Pay off Bank Loan (Non SBA Associated)*

Acquisition and/or Repair of Machinery and Equipment

Other Debt Payment (Non SBA Associated)

Inventory Purchase All Other

Working Capital (including Accounts Payable) Total Loan Requested

Acquisition of Existing Business Term of Loan - (Requested Maturity) Yrs.

CURRENT AND PREVIOUS SBA AND OTHER GOVERNMENT DEBT: Complete the chart below if you, your business, any principal of your business, any affiliate of your business, any other business currently owned by a principal, or any business previously owned by you or a

principal of your business has received or applied for any direct or guaranteed financial assistance from the Federal Government, including student

loans and disaster loans. All current, previous, and pending Government debt must be listed, including loans that have been paid in full or those that

resulted in a loss to the Government. (Note: Loans that resulted in a loss to the Government include loans that were charged off, compromised, or

discharged as a result of bankruptcy. The amount of the loss is the outstanding principal balance of the loan that the Government had to write off after

all collection activities (including compromise) were finalized.)

Name of Agency

Agency Loan #

Borrower’s Name Original

Amount of Loan

Date of Application

Loan Status Outstanding Balance $ Amount of Loss to the

Government.

$ $ $

ASSISTANCE: Did you commit to pay -- or have you paid -- anyone (including the lender) to assist you in either obtaining this loan (such as a

broker, consultant or referral agent) or in preparing the application or application materials for this loan (such as a loan packager)?

Note: The estimated burden completing this form is 12.0 hours per response. You will not be required to respond to collection of information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to the U.S. Small Business Administration, Chief, AIB, 409 3rd St., S.W., Washington, DC. 20416 and Desk Office for Small Business Administration, Office of Management and Budget, New Executive Building, room 10202 Washington, D.C. 20503. OMB Approval (3245-0016). PLEASE DO NOT SEND FORMS TO OMB. SUBMIT COMPLETED APPLICATION TO LENDER OF CHOICE.

Yes No

$ $ $

If "yes," complete SBA (7a) - (Fee Disclosure Form and Compensation Agreement) for each party that was paid or will be paid.)Form 159

SBA Form 4 (9-09) Previous Edition Obsolete Page 2

ALL EXHIBITS MUST BE SIGNED AND DATED BY PERSON SIGNING THIS FORM

BUSINESS INDEBTEDNESS: Furnish the following information on all outstanding installment debts, contracts, notes, and mortgages payable. Indicate by an asterisk (*) items to be paid by loan proceeds and reasons for paying them. (Present balance should agree with the latest balance sheet submitted).

To Whom Payable Original Amount

Original Date

Present Balance Rate of Interest

Maturity Date

Monthly Payment

Security Current or Past Due

Acct. # $ $ $

MANAGEMENT (Proprietor, partners, officers, directors, all holders of outstanding stock –100% of ownership must be shown.) Use separate sheet if necessary.

Name and Social Security Number Position/Title

Complete Address %

Owned

*Gender

*Veteran Status

Race * :Amer. Indian or Alaska Native Asian Black or African-Amer. Native Haw. or Pacific Islander White *Ethnicity:Hispanic or Latino Not Hisp or Lantino

Race *

*This data is collected for statistical purposes only. It has no bearing on the credit decision. Disclosure is voluntary. One or more boxes for race may be selected

For Guaranty Loans please provide an original and one copy (Photocopy

4. Include the financial statements listed below: a, b, c for the last is Acceptable) of the Application Form and all Exhibits to the

three years; also a, b, c, and d as of the same date, - current within participating Lender. For Direct Loans submit one original copy

90 days of filing the application; and statement e, if applicable. of the application and Exhibits to SBA.

All

information must be signed and dated.1.Submit SBA Form 912 (Statement of Personal History) for each

proprietor (if sole proprietorship), partner (if a partnership), and by each

officer, director, and owner of 20% or more of the company's stock (if a

corporation, limited liability company or development company).

(a) Balance Sheet; (b) Profit and Loss Statement (if not available, explain why and substitute

2. If your collateral consists of (A) Land and Building, (B) Machinery

Federal income tax forms); (c) Reconciliation of Net Worth; (d)

and Equipment, (C) Furniture and Fixtures, (D) Accounts Receivable, (E) Inventory, (F) Other, please provide an itemized list that contains

Aging of Accounts Receivable and and Payable (summary); (e)

serial and identification numbers for all articles that had an original value

Projection of earnings for at least one year where financial

of greater than $5,000. Include a legal description of Real Estate offered

statements for the last three years are unavailable or when SBA

as collateral. Label it Exhibit A.

requests them, Label it Exhibit C. (Contact SBA for a referral if

5. Provide a brief history of your company and a paragraph

3. Furnish a signed current personal balance sheet (SBA Form 413

describing the expected benefits it will receive from the loan. Label

may be used for this purpose) for (1) each proprietor; or (2) each limited

it Exhibit D.

partner who owns 20% or more interest and each general partner; or (3) each stockholder owning 20% or more of voting stock. Include the

6. Provide a brief description similar to a resume of the education, technical and business background for all the people listed under Management. Label it Exhibit E.

Also, include the tax i.d. number [EIN or Social Security Number

(SSN)] Label it Exhibit B.

:Amer. Indian or Alaska Native Asian Black or African-Amer. Native Haw. or Pacific Islander White

*Veteran Status

Veteran If yes, service-disabled?

If yes, service-disabled? Veteran

Yes No Yes No

:Amer. Indian or Alaska Native Asian Black or African-Amer. Native Haw. or Pacific Islander White

Yes No Yes No

*Ethnicity:Hispanic or Latino Not Hisp or Lantino

Acct. # $ $ $

assets and liabilities of the spouse and any minor children.

assistance with preparation is wanted.)

SBA Form 4 (9-09) Previous Edition Obsolete Page 3

AGREEMENTS AND CERTIFICATIONS

AGREEMENTS:

By signing below you agree to the following:

(a) Agreements of non-employment of SBA Personnel. I agree that

if SBA approves this application I will not, for at least two years,

hire as an employee or consultant anyone that was employed by the

SBA during the one year period prior to the loan disbursement.

If Applicant is a proprietor or general partner, sign below.

By:

If Applicant is a Corporation, sign below:

Corporate Name and Seal Date

By: Signature of President

Attested by: Signature of Corporate Secretary

7. Submit the name, addresses, tax I.D. number (EIN or SSN), and current personal financial statement of any co-signers who are not otherwise affiliated with the business and any guarantors for the loan not.

8. Include a list of any machinery or equipment or other non-real estate assets to be purchased with loan proceeds and the cost of each item as quoted by the seller. Include the seller’s name and address. Exhibit G.

9. Have you or any officer of your company ever been involved in bankruptcy or insolvency proceedings? [ ]Yes [ ]No. If yes, please provide the details as Exhibit H.

10. Are you or your business involved in any pending lawsuits?

If yes, provide the details as Exhibit I.

[ ]Yes

11.Do you or your spouse or any member of your household, or anyone who owns, manages, or directs your business or their spouses or members of their households work for the Small Business Administration, Small Business Advisory Council, SCORE or ACE, any Federal Agency, or the participating lender? address of the person and the office where employed. Label this Exhibit J.

12. Does your business, its owners or majority stockholders own or have a controlling interest in other businesses? If yes, please provide their names and the relationship with your company along with financial data requested in question 4. Label this Exhibit K.

13. Do you buy from, sell to, or use the services of any concern in which someone in your company has a significant financial interest? [ ]Yes [ ]No. If yes, provide details on a separate sheet of paper. Exhibit L.

14. Is your business is a franchise, If yes, include a copy of the franchise agreement and a copy of the FTC disclosure statement supplied to you by the Franchisor. Label this Exhibit M.

CONSTRUCTION LOANS ONLY

15. Include as a separate exhibit the estimated cost of the project and a statement of the source of any additional funds. Label this Exhibit N.

16. Provide copies of preliminary construction plans and specifications. Label this as Exhibit 0. Final plans will be required prior to disbursement.

EXPORT LOANS

17. Does your business currently export, or will it start exporting, pursuant to this loan (if approved) ? Check here: [ ]Yes [ ]No

18. If you answered yes to item 17, what is your estimate of the total export sales this loan would support? $ _____

19. Would you like information on Exporting? Check here: [ ]Yes [ ]No _ COUNSELING/TRAINING

20. Have you received counseling or training from SBA (e.g., SCORE, ACE, SBDC, WBC, etc.) ? Check here: [ ]Yes [ ]No

SUBMIT COMPLETED APPLICATION TO LENDER OF CHOICE.

[ ]No.

If yes, please provide the name and [ ]Yes [ ]No.

[ ]Yes [ ]No.

(b) Waiver of Claims. As consideration for any Management,

Technical, and/or Business Development Assistance that may be

provided, I waive all claims against SBA and its consultants.

General to request criminal record information about me from

criminal justice agencies for the purpose of determining my

eligibility for assistance under the Small Business Act.

(d) Reimbursement of Expenses. I agree to pay for or reimburse

SBA for the cost of any surveys, title or mortgage examinations,

appraisals, credit reports, etc., performed by non-SBA personnel

provided I have given my consent.

(e) Reporting. I agree to report to the SBA Office of the Inspector

General, Washington, DC 20416 any federal government employee

who offers, in return for any type of compensation, to help get this

loan approved.

READ THE FOLLOWING CAREFULLY -- FALSE STATE-

MENTS ARE SUBJECT TO CRIMINAL PROSECUTION:

If you knowingly make a false statement, you can be fined up to

$250,000 and/or imprisoned for not more than five years under

18 USC 1001; if submitted to a Federally insured institution,

under 18 USC 1014 by Imprisonment of not more than twenty

years and/or a fine of not more than $1,000,000

CERTIFICATIONS:

By signing below you certify as to the following:

(a) All information in this Application and the Exhibits is true

and complete to the best of your knowledge. You understand that

this information is being submitted to a lender and SBA so they can

decide to make a loan or give a loan guaranty, and that the lender

and SBA are relying on this information.

(b) You have not paid anyone employed by the Federal Government

for help in getting this loan. You understand that you do not need to

pay any other third-party for assistance in locating a lender or

preparing this Application or Exhibits, and you certify that you will

disclose all parties that were paid for such assistance to the

Lender and will complete the SBA Form 159 for all such persons.

Executive Order," which is attached to this application and agree to

comply with the requirements in this Notice.

covered by 3. above. Exhibit F.

SBA Form 4 (9-09) Previous Edition Obsolete Page 4

APPLICANT’S CERTIFICATION

Business Name:

Signature Date

Check all that apply: [ ] guarantor [ ] owner-indicate percentage owned: [ ] [ ] partner-indicate whether [ ] general or [ ] limited

Other than the person that signed on page 3, each Partner, each Stockholder owning 20% or more, and

each Guarantor must sign below. In addition, if a husband and wife collectively own 20% or more of a

company, each spouse must also sign. No one should sign more than once.

READ THE FOLLOWING CAREFULLY -- FALSE STATEMENTS ARE SUBJECT TO CRIMINAL PROSECUTION:

If you knowingly make a false statement, you can be fined up to $250,000 and/or imprisoned for not more than five years under 18 USC

1001; if submitted to a Federally insured institution, under 18 USC 1014 by Imprisonment of not more than twenty years and/or a fine of

not more than $1,000,000

By signing below you certify as to the following:

(a) You have reviewed (1) the responses to the question about debt on page 1 of the application; (2) the responses to questions 11, 12, and 13

(application-page 3), and (3) any financial statement that you were required to complete as Exhibit B or F to the application and certify that as to

you personally all information in this Application and Financial Statement is true and complete to the best of your knowledge. You

acknowledge that this information is being submitted to a lender and SBA so they can decide to make a loan or give a loan guaranty, and that the

lender and SBA are relying on this information.

(b) You have read a copy of the "Statements Required By Law And Executive Order," which is attached to this application and agree to comply

with the requirements in this Notice.

SBA Form 4 (9-09) Previous Edition Obsolete Page 5

PLEASE READ, DETACH, AND RETAIN FOR YOUR RECORDS STATEMENTS REQUIRED BY LAW AND EXECUTIVE ORDER

Federal executive agencies, including the Small Business Administration (SBA), are required to withhold or limit financial assistance, to impose special conditions 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 various inter-agency agreements. SBA has issued regulations and procedures that implement these laws and executive orders, and they are contained in Parts 112, 113, 116, and 117, Title 13, Code of Federal Regulations Chapter 1, or Standard Operating Procedures.

Freedom of Information Act (5 U.S.C. 552) This law provides, with some exceptions, that SBA must supply information reflected in agency files and records to a person requesting it. Information about approved loans that will be automatically released includes, among other things, statistics on our loan programs (individual borrowers are not identified in the statistics) and other information such as the names of the borrowers (and their officers, directors, stockholders or partners), the collateral pledged to secure the loan, the amount 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 be addressed to the nearest SBA office and be identified as a Freedom of Information request.

Privacy Act (5 U.S.C. 552a)

A person can request to see or get copies of any personal information that SBA has in his or her file when that file is retrievable 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 information is subject to disclosure under the Freedom of Information Act.

Under the provisions of the Privacy Act, you are not required to provide your social security number. Failure to provide your social security number may not affect any right, benefit or privilege to which you are entitled. Disclosures of name and other personal identifiers are, however, required for a benefit, as SBA requires an individual seeking assistance from SBA to provide it with sufficient information for it 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. In making loans pursuant to section 7(a)(6) of the Small Business Act (the Act), 15 USC Section 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. Additionally, SBA is specifically authorized to verify your criminal history, or lack thereof, pursuant to section 7(a)(1)(B), 15 USC Section 636(a)(1)(B). 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 Act or the Small Business Investment Act, 15 USC Sections 634(b)(11) and 687(b)(a). For these purposes, you are asked to voluntarily provide your social security number to assist SBA in making a character determination and to distinguish you from other individuals with the same or similar name or other personal identifier.

The Privacy Act authorizes SBA to make certain “routine uses” of information protected by that Act. One such routine use for SBA’s loan system of records is that when this information 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. Another routine use of personal information is to assist in obtaining credit bureau reports, including business credit reports on the small business borrower and consumer credit reports and scores on the principals of the small business and guarantors on the loan for purposes of originating, servicing, and liquidating small business loans and for purposes of routine periodic loan portfolio management and lender monitoring. See, 69 F.R. 58598, 58617 (and as amended from time to time) for additional background and other routine uses.

SBA Form 4 (5-09) Previous Edition Obsolete Page 6

Right to Financial Privacy Act of 1978 (12 U.S.C. 3401) This is notice to you as required by the Right of Financial Privacy Act of 1978, of SBA's access rights to financial records held by financial institutions that are or have been doing business with you or your business, including any financial institutions participating in a loan or loan guarantee. The law provides that SBA shall have a right of access to your financial records in connection with its consideration or administration of assistance to you in the form of a Government loan or loan guaranty agreement. SBA is required to provide a certificate of its compliance with the Act to a financial institution in connection with its first request for access to your financial records, after which no further certification is required for subsequent accesses. The law also provides that SBA's access rights continue for the term of any approved loan or loan guaranty agreement. No further notice to you of SBA's access rights is required during the term of any such agreement.

The law also authorizes SBA to transfer to another Government authority any financial records included in an application for a loan, or concerning an approved loan or loan guarantee, as necessary to process, service or foreclose on a loan or loan guarantee or to collect on a defaulted loan or loan guarantee. No other transfer of your financial records to another Government authority will be permitted by SBA except as required or permitted by law.

Flood Disaster Protection Act (42 U.S.C. 4011) Regulations have been issued by the Federal Insurance Administration (FIA) and by SBA implementing this Act and its amendments. These regulations prohibit SBA from making certain loans in an FIA designated floodplain unless Federal flood insurance is purchased as a condition of the loan. Failure to maintain the required level of flood insurance makes the applicant ineligible for any future financial assistance from SBA under any program, including disaster assistance.

Executive Orders -- Floodplain Management and Wetland Protection (42 F.R. 26951 and 42 F.R. 26961) The SBA discourages any settlement in or development of a floodplain or a wetland. This statement is to notify all SBA loan applicants that such actions are hazardous to both life and property and should be avoided. The additional cost of flood preventive construction must be considered in addition to the possible loss of all assets and investments in future floods.

Occupational Safety and Health Act (15 U.S.C. 651 et seq.) This legislation authorizes the Occupational Safety and Health Administration in the Department of Labor to require businesses to modify facilities and procedures to protect employees or pay penalty fees. In some instances the business can be forced to cease operations or be prevented from starting operations in a new facility. Therefore, in some instances SBA may require additional information from an applicant to determine whether the business will be in compliance with OSHA regulations and allowed to operate its facility after the loan is approved and disbursed. Signing this form as borrower is a certification that the OSA requirements that apply to the borrower's business have been determined and the borrower to the best of its knowledge is in compliance.

Civil Rights Legislation

All businesses receiving SBA financial assistance must agree not to discriminate in any business practice, including employment practices and services to the public, on the basis of categories cited in 13 C.F.R., Parts 112, 113, and 117 of SBA Regulations. This includes making their goods and services available to handicapped clients or customers. All business borrowers will be required to display the "Equal Employment Opportunity Poster" prescribed by SBA.

Equal Credit Opportunity Act (15 U.S.C. 1691) The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status or age (provided that the applicant has the capacity to enter into a binding contract); because all or part of the applicant's income derives from any public assistance program, or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The Federal agency that administers compliance with this law concerning this creditor is the Federal Trade Commission, Equal Credit Opportunity, Washington, D.C. 20580.

SBA Form 4 (4-09) Previous Edition Obsolete Page 7

Executive Order 11738 -- Environmental Protection (38 C.F.R. 25161) The Executive Order charges SBA with administering its loan programs in a manner that will result in effective enforcement of the Clean Air Act, the Federal Water Pollution Act and other environmental protection legislation. SBA must, therefore, impose conditions on some loans. By acknowledging receipt of this form and presenting the application, the principals of all small businesses borrowing $100,000 or more in direct funds stipulate to the following:

1. That any facility used, or to be used, by the subject firm is not cited on the EPA list of Violating Facilities.

2. That subject firm will comply with all the requirements of Section 114 of the Clean Air Act (42 U.S.C. 7414) and Section 308 of the Water Act (33 U.S.C 1318) relating to inspection, monitoring, entry, reports and information, as well as all other requirements specified in Section 114 and Section 308 of the respective Acts, and all regulations and guidelines issued thereunder.

3. That subject firm will notify SBA of the receipt of any communication from the Director of the Environmental Protection Agency indicating that a facility utilized, or to be utilized, by subject firm is under consideration to be listed on the EPA List of Violating Facilities.

Debt Collection Act of 1982 Deficit Reduction Act of 1984 (31 U.S.C. 3701 et seq. and other titles) These laws require SBA to aggressively collect any loan payments which become delinquent. SBA must obtain your taxpayer identification number when you apply for a loan. If you receive a loan, and do not make payments as they come due, SBA may take one or more of the following actions:

- Report the status of your loan(s) to credit bureaus - Hire a collection agency to collect your loan - Offset your income tax refund or other amounts due to you from the Federal Government - Suspend or debar you or your company from doing business with the Federal Government - Refer your loan to the Department of Justice or other attorneys for litigation - Foreclose on collateral or take other action permitted in the loan instruments.

Immigration Reform and Control Act of 1986 (Pub. L. 99-603) If you are an alien who was in this country illegally since before January 1, 1982, you may have been granted lawful temporary resident status by the United States Immigration and Naturalization Service pursuant to the Immigration Reform and Control Act of 1986 (Pub. L. 99-603). For five years from the date you are granted such status, you are not eligible for financial assistance from the SBA in the form of a loan or guaranty under section 7(a) of the Small Business Act unless you are disabled or a Cuban or Haitian entrant. When you sign this document, you are making the certification that the Immigration Reform and Control Act of 1986 does not apply to you, or if it does apply, more than five years have elapsed since you have been granted lawful temporary resident status pursuant to such 1986 legislation.

Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4821 et seq.) Borrowers using SBA funds for the construction or rehabilitation of a residential structure are prohibited from using lead- based paint (as defined in SBA regulations) on all interior surfaces, whether accessible or not, and exterior surfaces, such as stairs, decks, porches, railings, windows and doors, which are readily accessible to children under 7 years of age. A "residential structure" is any home, apartment, hotel, motel, orphanage, boarding school, dormitory, day care center, extended care facility, college or other school housing, hospital, group practice or community facility and all other residential or institutional structures where persons reside.

Executive Order 12549, Debarment and Suspension (13 C.F.R. 145)

1. The prospective lower tier participant certifies, by submission of this loan application, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

2. Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participants shall attach an explanation to the loan application.

OMB Approval No.: 3245-0016 Expiration Date: 11/30/2012

U.S. SMALL BUSINESS ADMINISTRATION SCHEDULE OF COLLATERAL

Exhibit A

Applicant

Street Address

City State Zip Code

LIST ALL COLLATERAL TO BE USED AS SECURITY FOR THIS LOAN

Section I – REAL ESTATE

Attach a copy of the deed(s) containing a full legal description of the land and show the location (street address) and city where the deed(s) is recorded. Following the address below, give a brief description of the improvements, such as size, type of construction, use, number of stories, and present condition (use additional sheet if more space is required).

LIST OF PARCELS OF REAL ESTATE

Address Year

Acquired

Original

Cost

Market

Value

Amount

of Lien

Name of

Lienholder

Description(s)

SBA Form 4, Schedule A (09-09) Previous Editions Obsolete SUBMIT COMPLETED APPLICATION TO LENDER OF CHOICE

Section II- PERSONAL PROPERTY All items with an original value greater than $5,000 listed herein must show manufacturer or make, model, year, and serial number. Items with no serial number must be clearly identified (use additional sheet if more space is required).

Description-Show Manufacturer,

Model, Serial No.

Year acquired Original Cost Market Value Current Lien Balance

Name of Lienholder

All information contained herein it TRUE and CORRECT to the best of knowledge. If you knowingly make a false

statement or overvalue a security to obtain a guaranteed loan from SBA, you can be fined up to $250,000 and/or imprisoned for not more than five years under 18 USC 1001; if submitted to a Federally insured institution, under 18 USC 1014 by Imprisonment of not more than twenty years and/or a fine of not more

than $1,000,000. I authorize the SBA’s Office of Inspector General 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, as amended.

Name Date

NOTE: The estimated burden for completing this form is 0.5 hours per response. You will not be required to respond to collection of information unless it displays a currently valid

OMB approval number. Comments on the burden should be sent to the U.S. Small Business Administration, Chief, AIB, 409 3rd. St., S.W. Washington, D.C., 20416 and Desk Office for Small Business Administration, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503.

OMB Approval (3245-0016).

SBA Form 4, Schedule A (09-09) Previous Editions Obsolete

OMB APPROVAL NO. 3245-0188 EXPIRATION DATE: 8/31/2011

PERSONAL FINANCIAL STATEMENT

U.S. SMALL BUSINESS ADMINISTRATION As of ,

Complete this form for: (1) each proprietor, or (2) each limited partner who owns 20% or more interest and each general partner, or (3) each stockholder owning 20% or more of voting stock, or (4) any person or entity providing a guaranty on the loan.

Name Business Phone

Residence Address Residence Phone

City, State, & Zip Code

Business Name of Applicant/Borrower

ASSETS

Cash on hand & in Banks

Savings Accounts

IRA or Other Retirement Account

Accounts & Notes Receivable

Life Insurance-Cash Surrender Value Only (Complete Section 8)

Stocks and Bonds (Describe in Section 3)

Real Estate (Describe in Section 4)

Automobile-Present Value

Other Personal Property (Describe in Section 5)

Other Assets (Describe in Section 5)

Total

Section 1. Source of Income

Salary

Net Investment Income

Real Estate Income

Other Income (Describe below)*

Description of Other Income in Section 1.

(Omit Cents) LIABILITIES (Omit Cents)

$ Accounts Payable $

$ Notes Payable to Banks and Others $

$ (Describe in Section 2)

$ Installment Account (Auto) $

$ Mo. Payments $

Installment Account (Other) $ $ Mo. Payments $

Loan on Life Insurance $

$ Mortgages on Real Estate $

(Describe in Section 4)

$ Unpaid Taxes $

$ (Describe in Section 6)

Other Liabilities $

$ (Describe in Section 7)

Total Liabilities $

Net Worth $

$ Total $

Contingent Liabilities

$ As Endorser or Co-Maker $

$ Legal Claims & Judgments $

$ Provision for Federal Income Tax $

$ Other Special Debt $

*Alimony or child support payments need not be disclosed in "Other Income" unless it is desired to have such payments counted toward total income.

(Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.)Section 2. Notes Payable to Banks and Others.

Original Current Payment Frequency How Secured or EndorsedName and Address of Noteholder(s) Balance Balance Amount (monthly,etc.) Type of Collateral

SBA Form 413 (10-08) Previous Editions Obsolete (tumble)

This form was electronically produced by Elite Federal Forms, Inc.

Section 3. Stocks and Bonds. (Use attachments if necessary. Each attachment must be identified as a part of this statement and signed).

Number of Shares Name of Securities Cost Market Value Date of

Total Value Quotation/Exchange Quotation/Exchange

Section 4. Real Estate Owned. (List each parcel separately. Use attachment if necessary. Each attachment must be identified as a part of this statement and signed.)

Property A Property B Property C

Type of Property

Address

Date Purchased

Original Cost

Present Market Value

Name &

Address of Mortgage Holder

Mortgage Account Number

Mortgage Balance

Amount of Payment per Month/Year

Status of Mortgage

(Describe, and if any is pledged as security, state name and address of lien holder, amount of lien, terms Section 5. Other Personal Property and Other Assets.

of payment and if delinquent, describe delinquency)

Section 6. Unpaid Taxes. (Describe in detail, as to type, to whom payable, when due, amount, and to what property, if any, a tax lien attaches.)

Section 7. Other Liabilities. (Describe in detail.)

Section 8. Life Insurance Held. (Give face amount and cash surrender value of policies - name of insurance company and beneficiaries)

I authorize SBA/Lender to make inquiries as necessary to verify the accuracy of the statements made and to determine my creditworthiness. I certify the above and the statements contained in the attachments are true and accurate as of the stated date(s). These statements are made for the purpose of either obtaining a loan or guaranteeing a loan. I understand FALSE statements may result in forfeiture of benefits and possible prosecution by the U.S. Attorney General (Reference 18 U.S.C. 1001).

Signature: Date: Social Security Number:

PLEASE NOTE: The estimated average burden hours for the completion of this form is 1.5 hours per response. If you have questions or comments concerning this estimate or any other aspect of this information, please contact Chief, Administrative Branch, U.S. Small Business Administration, Washington, D.C. 20416, and Clearance Officer, Paper Reduction Project (3245-0188), Office of Management and Budget, Washington, D.C. 20503. PLEASE DO NOT SEND FORMS TO OMB.

SBA Form 413 (10-08) Previous Editions Obsolete

Return Executed Copies 1, 2, and 3 to SBA

United States of America

SMALL BUSINESS ADMINISTRATION

STATEMENT OF PERSONAL HISTORY

OMB APPROVAL NO.3245-0178 Expiration Date:12/31/2009

Please Read Carefully - Print or Type

Each member of the small business or the development company requesting assistance must submit this form in TRIPLICATE for filing with the SBA application. This form must be filled out and submitted by:

Name and Address of Applicant (Firm Name)(Street, City, State, and ZIP Code) SBA District/Disaster Area Office

Amount Applied for (when applicable) File No. (if known)

1. 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.

First Middle Last

2. Give the percentage of ownership or stocked owned

3. Date of Birth (Month, day, and year)

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

U.S. Citizen? YES NO

If non- U.S. citizen provide alien registration number:

Address:

Present residence address:

From:

To:

Home Telephone No. (Include A/C):

Business Telephone No. (Include A/C):

Address:

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

From:

To:

PLEASE SEE REVERSE SIDE FOR EXPLANATION REGARDING DISCLOSURE OF INFORMATION AND THE USES OF SUCH INFORMATION.

IT IS IMPORTANT THAT THE NEXT THREE QUESTIONS BE ANSWERED COMPLETELY. AN ARREST OR CONVICTION RECORD WILL NOT NECESSARILY DISQUALIFY YOU; HOWEVER, AN UNTRUTHFUL ANSWER WILL CAUSE YOUR APPLICATION TO BE DENIED.

IF YOU ANSWER "YES" TO 7, 8, OR 9, FURNISH DETAILS ON A SEPARATE SHEET. INCLUDE DATES, LOCATION, FINES, SENTENCES, WHETHER MISDEMEANOR OR FELONY, DATES OF PAROLE/PROBATION, UNPAID FINES OR PENALTIES, NAME(S) UNDER WHICH CHARGED, AND ANY OTHER PERTINENT INFORMATION.

7. Are you presently under indictment, on parole or probation?

Yes No (If yes, indicate date parole or probation is to expire.)

8. Have you ever been charged with and or arrested for any criminal offense other than a minor motor vehicle violation? Include offenses which have been dismissed, discharged, or not prosecuted (All arrests and charges must be disclosed and explained on an attached sheet.)

Yes No

9. Have you ever been convicted, placed on pretrial diversion, or placed on any form of probati on, including adjudication withheld pending probation, for any criminal offense other than a minor vehicle violation?

Yes No

10. I authorize the Small Business Administration Office of Inspector General to r equest 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: 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 by imprisonment of not more than five years and/or a fine of not more than $10,000; 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

Fingerprints Waived Date Approving Authority

Fingerprints Required

Date Sent to OIG

Date Approving Authority

11. Cleared for Processing

Request a Character Evaluation Approving Authority

12.

SBA 912 (12-06) SOP 5010.4 Previous Edition Obsolete This form was electronically produced by Elite Federal Forms, Inc.

By the proprietor, if a sole proprietorship.

By each partner, if a partnership.

By each officer, director, and additionally by each holder of 20% or more of the ownership stock, if a corporation, limited liability company, or a development company.

PLEASE NOTE: The estimated burden for completing this form is 15 minutes per re sponse. You are not required to respond to any collection of information un less it displays a currently valid OMB approval number. Comments on the burden should be sent to U.S. Small Business Administration, Chief, AIB, 409 3rd St., S.W., Washington D.C. 20416 and Desk Officer for the Small Business Administration, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503. OMB Approval 3245-0178. PLEASE DO NOT SEND FORMS TO OMB.

Social Security No.

or to be owned in the small business or the development company

Name and Address of participating lender or surety co. (when applicable and kno wn)

If No, are you a Lawful Permanent resident alien:

YES NO

13.

(Required whenever 7, 8 or 9 are answered "yes" even if cleared for processing.)

Date

Date Approving Authority

NOTICES REQUIRED BY LAW

The following is a brief summary of the laws applicable to this solicitation of information.

Paperwork Reduction Act (44 U.S.C. Chapter 35)

SBA is collecting the information on this form to make a character and credit e ligibility decision to fund or deny you a loan or other form of assistance. The information is required in order for SBA to have sufficient information to determine whether to provide you with the requested assistance. The information collected may be checked against criminal history indices of the Federal Bureau of Investigation.

Privacy Act (5 U.S.C. § 552a)

Any person can request to see or get copies of any personal information that SBA has in his or her file, when that file is retrievable 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 information is subject to disclosure under the Free dom of Information Act.

Under the provisions of the Privacy Act, you are not required to provide your social security number. Failure to provide your social security number may not affect any right, benefit or privilege to which you are entitled. Disclosures of name and other personal identifiers are, however, required for a benefit, as SBA requires an individual seeking assistance from SBA to provide it with sufficient informatio n for it 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. In making loans pursuant to s ection 7(a)(6) the Small Business Act (the Act), 15 USC § 636 (a)(6), SBA is required to have reasonable assurance that the loan is of s ound value and will be repaid or that it is in the best interest of the Government to grant the assistance requested. Additionally, SBA is specifically authorized to verify your criminal history, or lack thereof, pursuant to section 7(a)(1)(B), 15 USC § 636(a)(1)(B). 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 v iolate or will violate the Act or the 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 in making a character determination and to distinguish you from other individuals with the same or similar name or other personal identifier.

When this information indicates a violation or potential violation of law, whet her 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, enforce ment or prevention of such violations. See 56 Fed. Reg. 8020 (1991) for other published routine uses.

4506-TForm Request for Transcript of Tax Return

OMB No. 1545-1872(Rev. January 2008)

Do not sign this form unless all applicable lines have been completed. Read the instructions on page 2.

Department of the Treasury Internal Revenue Service

Request may be rejected if the form is incomplete, illegible, or any required line was blank at the time of signature.

First social security number on tax return or

employer identification number (see instructions)

1a 1bName shown on tax return. If a joint return, enter the name shown first.

If a joint return, enter spouse’s name shown on tax return2a Second social security number if joint tax return2b

Current name, address (including apt., room, or suite no.), city, state, and ZIP code3

Form 4506-T (Rev. 1-2008)Cat. No. 37667NFor Privacy Act and Paperwork Reduction Act Notice, see page 2.

Previous address shown on the last return filed if different from line 34

Caution: DO NOT SIGN this form if a third party requires you to complete Form 4506-T, and lines 6 and 9 are blank.

If the transcript or tax information is to be mailed to a third party (such as a mortgage company), enter the third party’s name, address, and telephone number. The IRS has no control over what the third party does with the tax information.

9 Year or period requested. Enter the ending date of the year or period, using the mm/dd/yyyy format. If you are requesting more than four years or periods, you must attach another Form 4506-T. For requests relating to quarterly tax returns, such as Form 941, you must enter each quarter or tax period separately.

Telephone number of taxpayer on line 1a or 2a

Sign

Here

( )

DateSignature (see instructions)

Title (if line 1a above is a corporation, partnership, estate, or trust)

Signature of taxpayer(s). I declare that I am either the taxpayer whose name is shown on line 1a or 2a, or a person authorized to obtain the tax information requested. If the request applies to a joint return, either husband or wife must sign. If signed by a corporate officer, partner, guardian, tax matters partner, executor, receiver, administrator, trustee, or party other than the taxpayer, I certify that I have the authority to execute Form 4506-T on behalf of the taxpayer.

Spouse’s signature Date

Tip: Use Form 4506-T to order a transcript or other return information free of charge. See the product list below. You can also call 1-800-829-1040 to

order a transcript. If you need a copy of your return, use Form 4506, Request for Copy of Tax Return. There is a fee to get a copy of your return.

/ / / / / / / /

Transcript requested. Enter the tax form number here (1040, 1065, 1120, etc.) and check the appropriate box below. Enter only one tax

form number per request.

Return Transcript, which includes most of the line items of a tax return as filed with the IRS. Transcripts are only available for the following returns: Form 1040 series, Form 1065, Form 1120, Form 1120A, Form 1120H, Form 1120L, and Form 1120S. Return transcripts are available for the current year and returns processed during the prior 3 processing years. Most requests will be processed within 10 business days

Account Transcript, which contains information on the financial status of the account, such as payments made on the account, penalty assessments, and adjustments made by you or the IRS after the return was filed. Return information is limited to items such as tax liability

and estimated tax payments. Account transcripts are available for most returns. Most requests will be processed within 30 calendar days

Record of Account, which is a combination of line item information and later adjustments to the account. Available for current year and 3 prior tax years. Most requests will be processed within 30 calendar days

Verification of Nonfiling, which is proof from the IRS that you did not file a return for the year. Most requests will be processed within 10 business days

Form W-2, Form 1099 series, Form 1098 series, or Form 5498 series transcript. The IRS can provide a transcript that includes data from

these information returns. State or local information is not included with the Form W-2 information. The IRS may be able to provide this transcript

information for up to 10 years. Information for the current year is generally not available until the year after it is filed with the IRS. For example,

W-2 information for 2006, filed in 2007, will not be available from the IRS until 2008. If you need W-2 information for retirement purposes, you

should contact the Social Security Administration at 1-800-772-1213. Most requests will be processed within 45 days

Caution: If you need a copy of Form W-2 or Form 1099, you should first contact the payer. To get a copy of the Form W-2 or Form 1099 filed with your return, you must use Form 4506 and request a copy of your return, which includes all attachments.

Page 2 Form 4506-T (Rev. 1-2008)

Mail or fax to the “Internal Revenue Service” at:

If you filed an individual return and lived in:

RAIVS Team Stop 679 Andover, MA 05501

978-247-9255

District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New York, Vermont

RAIVS Team P.O. Box 47-421 Stop 91 Doraville, GA 30362

770-455-2335

Alabama, Delaware, Florida, Georgia, North Carolina, Rhode Island, South Carolina, Virginia

RAIVS Team Stop 6716 AUSC Austin, TX 73301

Kentucky, Louisiana, Mississippi, Tennessee, Texas, a foreign country, or A.P.O. or F.P.O. address

If you have comments concerning the accuracy of these time estimates or suggestions for making Form 4506-T simpler, we would be happy to hear from you. You can write to the Internal Revenue Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, IR-6526, Washington, DC 20224. Do not send the form to this address. Instead, see Where to file on this page.

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to establish your right to gain access to the requested tax information under the Internal Revenue Code. We need this information to properly identify the tax information and respond to your request. Sections 6103 and 6109 require you to provide this information, including your SSN or EIN. If you do not provide this information, we may not be able to process your request. Providing false or fraudulent information may subject you to penalties.

The time needed to complete and file Form 4506-T will vary depending on individual circumstances. The estimated average time is: Learning about the law or the form, 10 min.; Preparing the form, 12 min.; and Copying, assembling, and sending the form to the IRS, 20 min.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by section 6103.

General Instructions Purpose of form. Use Form 4506-T to request tax return information. You can also designate a third party to receive the information. See line 5.

Signature and date. Form 4506-T must be signed and dated by the taxpayer listed on line 1a or 2a. If you completed line 5 requesting the information be sent to a third party, the IRS must receive Form 4506-T within 60 days of the date signed by the taxpayer or it will be rejected.

Individuals. Transcripts of jointly filed tax returns may be furnished to either spouse. Only one signature is required. Sign Form 4506-T exactly as your name appeared on the original return. If you changed your name, also sign your current name.

Corporations. Generally, Form 4506-T can be signed by: (1) an officer having legal authority to bind the corporation, (2) any person designated by the board of directors or other governing body, or (3) any officer or employee on written request by any principal officer and attested to by the secretary or other officer.

Partnerships. Generally, Form 4506-T can be signed by any person who was a member of the partnership during any part of the tax period requested on line 9.

All others. See Internal Revenue Code section 6103(e) if the taxpayer has died, is insolvent, is a dissolved corporation, or if a trustee, guardian, executor, receiver, or administrator is acting for the taxpayer.

Where to file. Mail or fax Form 4506-T to the address below for the state you lived in, or the state your business was in, when that return was filed. There are two address charts: one for individual transcripts (Form 1040 series and Form W-2) and one for all other transcripts.

If you are requesting more than one transcript or other product and the chart below shows two different RAIVS teams, send your request to the team based on the address of your most recent return.

Chart for individual transcripts (Form 1040 series and Form W-2)

RAIVS Team Stop 37106 Fresno, CA 93888

559-456-5876

Alaska, Arizona, California, Colorado, Hawaii, Idaho, Iowa, Kansas, Minnesota, Montana, Nebraska, Nevada, New Mexico, North Dakota, Oklahoma, Oregon, South Dakota, Utah, Washington, Wisconsin, Wyoming

RAIVS Team

Stop 6705–B41

Kansas City, MO 64999

816-292-6102

Arkansas, Connecticut, Illinois, Indiana, Michigan, Missouri, New Jersey, Ohio, Pennsylvania, West Virginia

Mail or fax to the “Internal Revenue Service” at:

RAIVS Team P.O. Box 9941 Mail Stop 6734 Ogden, UT 84409

Alabama, Alaska, Arizona, Arkansas, California, Colorado, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Louisiana, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Mexico, North Dakota, Oklahoma, Oregon, South Dakota, Tennessee, Texas, Utah, Washington, Wyoming, a foreign country, or A.P.O. or F.P.O. address

Connecticut, Delaware, District of Columbia, Illinois, Indiana, Kentucky, Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, South Carolina, Vermont, Virginia, West Virginia, Wisconsin

RAIVS Team P.O. Box 145500 Stop 2800 F Cincinnati, OH 45250

859-669-3592

Chart for all other transcripts

Documentation. For entities other than individuals, you must attach the authorization document. For example, this could be the letter from the principal officer authorizing an employee of the corporation or the Letters Testamentary authorizing an individual to act for an estate.

Line 1b. Enter your employer identification number (EIN) if your request relates to a business return. Otherwise, enter the first social security number (SSN) shown on the return. For example, if you are requesting Form 1040 that includes Schedule C (Form 1040), enter your SSN.

Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation, and cities, states, and the District of Columbia for use in administering their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

Tip. Use Form 4506, Request for Copy of Tax Return, to request copies of tax returns.

Line 6. Enter only one tax form number per request.

If you lived in or your business was in:

512-460-2272

801-620-6922 Note. You can also call 1-800-829-1040 to request a transcript or get more information.

Department of Homeland Security

U.S. Citizenship and Immigration Services G-845, Document Verification Request

OMB No. 1615-0101; Expires 07/31/2011

To: U.S. Citizenship and Immigration Services (USCIS)

Section A. To Be Completed by the Submitting Agency

From: Typed or Stamped Name and Address of Submitting Agency

Attn: Immigration Status Verification Unit

(USCIS may use above address with a No. 10 window envelope)

1. Alien Registration Number or Form I-94 Number

2. Applicant's Name (Last, First, Middle)

3. Nationality

4. Date of Birth (mm/dd/yyyy)

5. U.S. Social Security Number

7. Photocopy of Document Attached

(If printed on both sides, attach a copy of the front and back.)

6. Verification Number

Other Information Attached (Specify documents)

8. Organization (Specify)

12. Telephone Number

11. Date (mm/dd/yyyy)

(

9. Name of Submitting Official

10. Title of Submitting Official

)

Section B. To Be Completed by USCIS

USCIS RESPONSES: From the documents or information submitted and/or a review of our records, we find that:

a. Expired

c. Counterfeit

b. Altered

1. This document appears valid and relates to a Lawful

Permanent Resident alien of the United States.

2. This document appears valid and relates to a Conditional

Resident alien of the United States.

3. This document appears valid and relates to an alien authorized

employment as indicated below:

4. This document appears valid and relates to an alien who has an

application pending for:

5. This document relates to an alien having been granted asylum/

refugee status in the United States.

6. This document appears valid and relates to an alien paroled

into the United States pursuant to Section 212 of the I&N Act.

7. This document appears valid and relates to an alien who is a

Cuban/Haitian entrant.

a. Full-Time

b. Part-Time

c. No Expiration (Indefinite)

d. Expires on (Specify mm/dd/yyyy below):

(Specify USCIS benefit below)

This document appears valid and relates to an alien who is a

conditional entrant. 8.

(Specify type or class below)

This document appears valid and relates to an alien who is a

nonimmigrant. 9.

This document appears valid and relates to an alien not

authorized employment in the United States. 10.

Continue to process as legal alien. USCIS is searching indices

for further information. 11.

This document is not valid because it appears to be:

(Check all that apply) 12.

USCIS Stamp

Form G-845 (Rev.07/25/08)Y

13. No determination can be made from the information submitted. Please obtain a copy of the original alien registration

documentation and resubmit.

14. No determination can be made without seeing both sides of the document submitted. (Please resubmit request.)

15. Copy of document is not readable. (Please resubmit request.)

Comments

Form G-845 (Rev. 07/25/08)Y Page 2

1. Submit copies (front and back) of alien's original documentation.

2. Make certain a complete return address has been entered in the "From" portion of the form.

3. The Alien Registration Number (A-number) is the letter "A" followed by a series of seven, eight, or nine digits. The number found

on Form I-94 may also be recorded in the block. (Check the front and back of the Form I-94 document. If the A-number appears,

record that number when requesting information, instead of the longer admission number, because the A-number refers to the

most integral record available.)

4. If Form G-845 is submitted without copies of the applicant's original documentation, it will be returned to the submitting agency

without any action taken.

5. Address this verification request to the U.S. Citizenship and Immigration Services verification office assigned to you by the

SAVE Program Office. For further information, please visit www.uscis.gov.

Instructions

Paperwork Reduction Act

An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information

unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at

5 minutes per response, including the time for reviewing instructions and completing and submitting the form. Send comments

regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:

U.S. Citizenship and Immigration Services, Regulatory Management Division, 111 Massachusetts Avenue, N.W., 3rd Floor, Suite

3008, Washington, DC 20529, OMB No. 1615-0101. Do not mail your application to this address.

Permanently Residing Under Color of Law "PRUCOL"

PRUCOL requests can only be submitted by the Social Security Administration for Supplemental Security Income cases that pre-date

August 22, 1996.

16. USCIS is actively pursuing the removal of an alien in this class/category.

17. USCIS is not actively pursuing the removal of an alien in this class/category at this time.

18. Other.

Department of Homeland Security

U.S. Citizenship and Immigration Services

G-845 Supplement, Document

Verification Request Supplement

To Be Completed by the Submitting Agency

To Be Completed by USCIS

To: U.S. Citizenship and Immigration Services

From: Typed or Stamped Name and Address of Submitting Agency

Complete the following items:

1. Immigration Status (Check all that apply):

a. Lawful Permanent Resident (LPR) alien of the United States.

b. Refugee admitted to the United States under Section 207 of the INA. (Complete Item 2 below.)

c. Asylee under Section 208 of the INA. (Complete Item 3 below.)

d. Alien whose deportation has been withheld under Section 243(h) of the INA (as in effect prior to April 1, 1997) or whose

removal has been withheld under Section 241(b)(3).

Alien paroled into the United States under Section 212(d)(5) of the INA for a period of at least one year.

(Complete Items 3 and 4 below.)

Conditional Entrant pursuant to Section 203(a)(7) of the INA prior to April 1, 1980.

American Indian born in Canada to whom the provisions of Section 289 of the INA apply.

h. Cuban/Haitian Entrant, as defined in Section 501(e) of the Refugee Education Assistance Act of 1980.

i. Amerasian immigrant, pursuant to Section 584 of the Foreign Operations, Export Financing, and Related Programs

Appropriations Act of 1988. (Complete Item 2 below.)

j. Other (indicate status):

Form G-845 Supplement (07/25/08)

For SSA Use Only: Alleged 08/22/96 status:

From the document or information submitted and/or a review of our records, we find that the person identified is a/an:

(Complete b, c, d, g, h or i if alien adjusted to LPR status from one of those statuses in the past seven years.)

(Complete Item 3 below.)

2. Date alien entered the United States:

3. Date status was granted:

4. Date status expires:

Date (mm/dd/yyyy)

Date deportation or removal ordered withheld:

OMB No. 1615-0101; Expires 07/31/2011

Phone Number (Include Area Code)

( )

Applicant's Name (Last, First, Middle)

Alien Registration Number or I-94 Number Social Security

Show 08/22/96 status in #1 j.

# 1 # 2 # 3 # 4 # 5 # 6 # 7

5. Citizenship Status:

7. Affidavit of Support:

Sponsor's U.S. Social Security Number

Form G-845 Supplement (07/25/08) Page 2

6. Special Benefit Provision for Certain Victims of Abuse:

a. This alien obtained Lawful Permanent (or Conditional) Resident Status as the spouse, child, or widow(er) of a U.S.

citizen.

b. This alien obtained Lawful Permanent (or Conditional) Resident Status as the spouse, child, or unmarried son or

daughter of a lawful permanent resident alien.

c. This alien did not obtain status as described in (a) or (b) above under Item 6.

a. This alien was sponsored on Form I-864, Affidavit of Support, under Section 213A of the INA.

Service receipt date:

b. This alien was not sponsored on Form I-864.

(Complete Item 3 on Page 1.)

Joint Sponsor's U.S. Social Security Number

USCIS Stamp

See attached for information on additional joint

sponsor(s).

To Be Completed by USCIS (Continued.)

This document appears valid and relates to a U.S. citizen.

Name of Sponsor

Sponsor's Address

Name of Joint Sponsor(s) (if any)

Joint Sponsor's Address

NOTE: This supplement may be used in conjunction with Form G-845 to

request verification: it cannot be used alone. It reflects information that

may be relevant to eligibility for Federal, State, and local public benefits

under the Personal Responsibility and Work Opportunity

Reconciliation Act of 1996, P.L. 104-193.

Paperwork Reduction Act

An agency may not conduct or sponsor an information collection and a

person is not required to respond to a collection of information unless it

displays a currently valid OMB control number. The public reporting

burden for this collection of information is estimated at 5 minutes per

response, including the time for reviewing instructions and completing and

submitting the form. Send comments regarding this burden estimate or any

other aspect of this collection of information, including suggestions for

reducing this burden, to: U.S. Citizenship and Immigration Services,

Regulatory Management Division, 111 Massachusetts Avenue, N.W., 3rd

Floor, Suite 3008, Washington, DC 20529. OMB No. 1615-0101. Do not

mail your application to this address.

PERSONAL CASH FLOW STATEMENT NAMES:

Provide the following information regarding sources and uses of personal cash during the most recent calendar year and your projections for the current year and the next year. Explain any cash flow deficit.

TYPE: BASIS:

SOURCES OF CASH Salaries/Wages (net of deductions) -$ -$ -$

Commissions / Bonuses (net of deductions) -$ -$ -$

Rental Income -$ -$ -$

Dividend Income -$ -$ -$

Distributions from Estates & Trusts -$ -$ -$

Cash Received from Individual Business(es), -$ -$ -$

Partnership(s), or Joint Ventures -$ -$ -$

Other: -$ -$ -$

TOTAL INCOME/CASH FLOW -$ -$ -$

USES OF CASH Propsoed Loan (Interest) -$ -$ -$

Other Loans (Principal & Interest) -$ -$ -$

Personal Housing Expense (Mortgage or Rent) -$ -$ -$

Mortgage Loans (P&I) (Not including personal -$ -$ -$

residence) -$ -$ -$

Insurance -$ -$ -$

Income Taxes not covered by withholding -$ -$ -$

Utilities-Electric, Gas, Water, Telephone -$ -$ -$

Personal Expenses (Food, Clothing, -$ -$ -$

Entertainment, etc.) -$ -$ -$

Credit Cards and other revolving debt -$ -$ -$

Other: -$ -$ -$

TOTAL CASH OUTLAYS -$ -$ -$

CASH FLOW SURPLUS (Deficit) -$ -$ -$

The undersigned certifies that the information provided herein is true and correct.

Signature: Date:

Spouse Signature: Date:

Individual Joint Monthly Annual

METRO CITY BANK

NEW LOAN REQUEST CUSTOMER INFORMATION FORM

Borrower Telephone DBA Name Cell Phone Address City, State & Zip Business Type Tax ID Loan Amount & Purpose Principle / Guarantor Home Phone SS# Acceptable Identification* Expiration Date Borrower and Principle / Guarantor have applied for a business loan from Lender. Lender may be relying on the creditworthiness of the Principle / Guarantor other than the Borrower for the business loan. Because of my relationship to the Borrower or my role in the accommodation for the loan, my personal creditworthiness is a factor in the evaluation of the application or accommodation for the loan By signing below, I authorize Lender to obtain a customer credit report on me for the purpose of evaluating the loan application of any future loan applications (to include renewals of existing loans) Principle / Guarantor Signature: SIGNATURE DATE * Driver’s license and/or passport

MANAGEMENT RESUME

Please fill in all spaces. If an item is not applicable, please indicate as such. You may include additional relevant information on a separate exhibit. SIGN/DATE where indicated

PERSONAL INFORMATION: NAME SS# DATE OF BIRTH PLACE OF BIRTH RESIDENCE TELEPHONE BUSINESS TELEPHONE RESIDENCE ADDRESS FROM TO PRESENT DATE PREVIOUS ADDRESS FROM TO PRESENT DATE SPOUSE’S NAME SS# ARE YOU EMPLOYED BY THE U.S. GOVERNMENT? AGENCY/POSITION ARE YOU A U.S. CITIZEN? IF NO, GIVE ALIEN REGISTRATION NUMBER EDUCATION: High School/College/Technical-Name/Location Dates Attended Major Degree/Certificate MILITARY SERVICE BACKGROUD: Branch of Service Date of Service

WORK EXPERIENCE: List chronologically beginning with present employment. Company Name/Location From To Title Duties Company Name/Location From To Title Duties Company Name/Location From To Title Duties SIGNATURE DATE

SBAForm4h.pdf

Sheet1

Individual:
Full Address:
Tax ID No or SSN:
Full Street Address of Business:
Tel No inc Area Code:
County:
At Time of Application:
Type of Business:
Date Business Established:
If Loan is Approved:
Bank of Business Account and Address:
Subsidiaries or Affiliates:
Loan RequestedLand Acquisition:
Loan RequestPay off SBA Loan:
Loan RequestedNew Construction Expansion Repair:
Loan RequestPay off Bank Loan Non SBA Associated:
Loan RequestedAcquisition andor Repair of Machinery and Equipment:
Loan RequestOther Debt Payment Non SBA Associated:
Loan RequestedInventory Purchase:
Loan RequestAll Other:
Loan RequestedWorking Capital including Accounts Payable:
Loan RequestTotal Loan Requested:
Loan RequestedAcquisition of Existing Business:
1:
Borrowers NameRow1:
Date of Application:
Loan Status:
2:
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Date of Application_2:
Loan Status_2:
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3:
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fill_22:
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4:
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Acct:
Original Date:
Rate of Interest:
Maturity Date:
Security:
Current or Past Due:
Acct_2:
Original Date_2:
Rate of Interest_2:
Maturity Date_2:
Security_2:
Current or Past Due_2:
Acct_3:
Original Date_3:
Rate of Interest_3:
Maturity Date_3:
Security_3:
Current or Past Due_3:
Rate of Interest_4:
Maturity Date_4:
Security_4:
Current or Past Due_4:
Rate of InterestRow5:
Maturity DateRow5:
Security_5:
Current or Past Due_5:
Name and Social Security Number PositionTitleRow1:
18 If you answered yes to item 17 what is your estimate of the:
If Applicant is a proprietor or general partner sign below:
Borrowers NameRow2:
Borrowers NameRow3:
Borrowers NameRow4:
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fill_41:
fill_70:
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Acct_4:
Acct_5:
Original Date_5:
Original Date_4:
Orig_Amt1:
Orig_Amt2:
Orig_Amt3:
Orig_Amt4:
Orig_Amt5:
Present_Bal1:
Present_Bal2:
Present_Bal3:
Present_Bal4:
Present_Bal5:
Monthly_Pay1:
Monthly_Pay2:
Monthly_Pay4:
Monthly_Pay5:
Race Amer Indian or Alaska Native Asian Black or AfricanAmer Native Haw or Pacific Islander WhiteRow1:
Race Amer Indian or Alaska Native Asian Black or AfricanAmer Native Haw or Pacific Islander WhiteRow1_2:
Race Amer Indian or Alaska Native Asian Black or AfricanAmer Native Haw or Pacific Islander WhiteRow1_3:
Race Amer Indian or Alaska Native Asian Black or AfricanAmer Native Haw or Pacific Islander WhiteRow1_4:
Race Amer Indian or Alaska Native Asian Black or AfricanAmer Native Haw or Pacific Islander WhiteRow2:
Race Amer Indian or Alaska Native Asian Black or AfricanAmer Native Haw or Pacific Islander WhiteRow5:
Complete AddressRow1:
Complete AddressRow5:
OwnedRow1:
OwnedRow2:
Gender2: [------------]
Gender3: [------------]
Gender1: [------------]
Gender4: [------------]
If Applicant is a Corporation sign below:
Date1:
Corporate Name and Seal:
Sig1:
Text6:
Percent1:
Percent2:
Percent3:
Percent4:
Percent5:
Percent6:
Percent7:
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Monthly_Pay6:
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loanrequestyears:
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Radio Button19: Off
Text61:
Text62:
Text63:
Text64:
Text65:
Text66:
Date41:
Date42:
Date43:
Date44:
Date45:
Date46:
Applicant:
Street Address:
City:
State:
Zip:
AddressRow1:
Year AcquiredRow1:
Original CostRow1:
Market ValueRow1:
Amount of LienRow1:
Name of LienholderRow1:
AddressRow2:
Year AcquiredRow2:
Original CostRow2:
Market ValueRow2:
Amount of LienRow2:
Name of LienholderRow2:
AddressRow3:
Year AcquiredRow3:
Original CostRow3:
Market ValueRow3:
Amount of LienRow3:
Name of LienholderRow3:
AddressRow4:
Year AcquiredRow4:
Original CostRow4:
Market ValueRow4:
Amount of LienRow4:
Name of LienholderRow4:
AddressRow5:
Year AcquiredRow5:
Original CostRow5:
Market ValueRow5:
Amount of LienRow5:
Name of LienholderRow5:
AddressRow6:
Year AcquiredRow6:
Original CostRow6:
Market ValueRow6:
Amount of LienRow6:
Name of LienholderRow6:
AddressRow7:
Year AcquiredRow7:
Original CostRow7:
Market ValueRow7:
Amount of LienRow7:
Name of LienholderRow7:
AddressRow8:
Year AcquiredRow8:
Original CostRow8:
Market ValueRow8:
Amount of LienRow8:
Name of LienholderRow8:
DescriptionsRow1:
DescriptionsRow2:
DescriptionsRow3:
DescriptionsRow4:
DescriptionsRow5:
DescriptionsRow6:
DescriptionsRow7:
DescriptionsRow8:
DescriptionsRow9:
DescriptionShow Manufacturer Model Serial NoRow1:
Year acquiredRow1:
Name of LienholderRow1_2:
DescriptionShow Manufacturer Model Serial NoRow2:
Year acquiredRow2:
Name of LienholderRow2_2:
DescriptionShow Manufacturer Model Serial NoRow3:
Year acquiredRow3:
Name of LienholderRow3_2:
DescriptionShow Manufacturer Model Serial NoRow4:
Year acquiredRow4:
Name of LienholderRow4_2:
DescriptionShow Manufacturer Model Serial NoRow5:
Year acquiredRow5:
Name of LienholderRow5_2:
DescriptionShow Manufacturer Model Serial NoRow6:
Year acquiredRow6:
Name of LienholderRow6_2:
DescriptionShow Manufacturer Model Serial NoRow7:
Year acquiredRow7:
Name of LienholderRow7_2:
DescriptionShow Manufacturer Model Serial NoRow8:
Year acquiredRow8:
Name of LienholderRow8_2:
DescriptionShow Manufacturer Model Serial NoRow9:
Year acquiredRow9:
Name of LienholderRow9:
DescriptionShow Manufacturer Model Serial NoRow10:
Year acquiredRow10:
Name of LienholderRow10:
DescriptionShow Manufacturer Model Serial NoRow11:
Year acquiredRow11:
Name of LienholderRow11:
DescriptionShow Manufacturer Model Serial NoRow12:
Year acquiredRow12:
Name of LienholderRow12:
DescriptionShow Manufacturer Model Serial NoRow13:
Year acquiredRow13:
Name of LienholderRow13:
DescriptionShow Manufacturer Model Serial NoRow14:
Year acquiredRow14:
Name of LienholderRow14:
DescriptionShow Manufacturer Model Serial NoRow15:
Year acquiredRow15:
Name of LienholderRow15:
DescriptionShow Manufacturer Model Serial NoRow16:
Year acquiredRow16:
Name of LienholderRow16:
DescriptionShow Manufacturer Model Serial NoRow17:
Year acquiredRow17:
Name of LienholderRow17:
DescriptionShow Manufacturer Model Serial NoRow18:
Year acquiredRow18:
Name of LienholderRow18:
DescriptionShow Manufacturer Model Serial NoRow19:
Year acquiredRow19:
Name of LienholderRow19:
DescriptionShow Manufacturer Model Serial NoRow20:
Year acquiredRow20:
Name of LienholderRow20:
DescriptionShow Manufacturer Model Serial NoRow21:
Year acquiredRow21:
Name of LienholderRow21:
DescriptionShow Manufacturer Model Serial NoRow22:
Year acquiredRow22:
Name of LienholderRow22:
DescriptionShow Manufacturer Model Serial NoRow23:
Year acquiredRow23:
Name of LienholderRow23:
DescriptionShow Manufacturer Model Serial NoRow24:
Year acquiredRow24:
Name of LienholderRow24:
DescriptionShow Manufacturer Model Serial NoRow25:
Year acquiredRow25:
Name of LienholderRow25:
DescriptionShow Manufacturer Model Serial NoRow26:
Year acquiredRow26:
Name of LienholderRow26:
Date:
Name_2:
As of:
asofyear:
BusinessPhone:
Name:
City,State,Zip:
Business Name:
AP:
Notes:
Installment:
Installment2:
Loan on LIfe:
Mortgages:
Unpaid tax:
Other liabilities:
Total Liabilities: 0
Networth: 0
Total: 0
Endorser:
Legal Claim:
undefined_16:
undefined_17:
Provision:
undefined_18:
Other Debt:
Description:
Description2:
Description3:
Name1:
Name2:
Name4:
Name3:
Name5:
Original BalanceRow1:
Current BalanceRow1:
Payment AmountRow1:
Frequency monthlyetcRow1:
How Secured or Endorsed Type of CollateralRow1:
Original BalanceRow2:
Current BalanceRow2:
Payment AmountRow2:
Frequency monthlyetcRow2:
How Secured or Endorsed Type of CollateralRow2:
Original BalanceRow3:
Current BalanceRow3:
Payment AmountRow3:
Frequency monthlyetcRow3:
How Secured or Endorsed Type of CollateralRow3:
Original BalanceRow4:
Current BalanceRow4:
Payment AmountRow4:
Frequency monthlyetcRow4:
How Secured or Endorsed Type of CollateralRow4:
Original BalanceRow5:
Current BalanceRow5:
Payment AmountRow5:
Frequency monthlyetcRow5:
How Secured or Endorsed Type of CollateralRow5:
NumberOfShares:
NameSec:
Market:
DateEx:
TotalV:
Cost:
NumberOfShares1:
NumberOfShares2:
NumberOfShares3:
NameSec1:
NameSec2:
NameSec3:
Cost1:
Cost2:
Cost3:
Market1:
DateEx1:
Market2:
Market3:
DateEx2:
DateEx3:
TotalV1:
TotalV2:
TotalV3:
TypeofProperty:
TypeofProperty1:
TypeofProperty2:
AddressProp:
AddressProp1:
AddressProp2:
DatePur:
DatePur1a:
DatePur2:
OrigCost:
OrigCost2:
OrigCost1:
PresentMark1:
PresentMark:
PresentMark2:
nameaddressMort:
nameaddressMort1:
nameaddressMort2:
MortAcct:
MortAcct2:
MortAcct1:
MortBal:
MortBal1:
MortBal2:
AmtPay:
AmtPay1:
AmtPay2:
StatusOfMort:
StatusOfMort2:
StatusOfMort1:
OtherPersonal:
UpaidTaxes:
LifeInsurance:
OtherLiabilities:
Date200:
Date Social Security Number:
Signature_2:
Date2001:
Date Social Security Number_2:
Name and Address of Applicant Firm NameStreet City State and ZIP Code:
SBA DistrictDisaster Area Office:
Amount Applied for when applicable:
File No if known:
Percentage:
Social Security No:
Middle1:
Last:
First1:
First2:
Middle2:
First3:
Middle3:
3 Date of Birth Month day and year:
Last2:
Last3:
4 Place of Birth City State or Foreign Country:
Name and Address of Applicant Firm NameStreet City State and ZIP Code2:
cit1: Off
cit2: Off
If non US citizen provide alien registration number:
From2:
to2:
FAddress:
HomePhone:
TAddress:
BussPhone:
cit3: Off
7 Are you presently under indictment on parole or probation Yes No If yes indicate date parole or probation is to expire:
cit4: Off
cit5: Off
Chex20: Off
Chex16: Off
Chex18: Off
Signature1:
Date_2:
Approving Authority:
Chex21: Off
Date_3:
Approving Authority_2:
Date Sent to OIG:
Date_4:
Approving Authority_3:
Date_5:
Approving Authority_4:
1a Name shown on tax return If a joint return enter the name shown first:
First social security number on tax return or employer identification number see instructions 1b:
If a joint return enter spouses name shown on tax return 2a:
Social:
Social1:
Social2:
Previous address shown on the last return filed if different from line 3:
If the transcript or tax information is to be mailed to a third party such as a mortgage company enter the third partys name address:
Transcript:
Transcript requested Enter the tax form number here 1040 1065 1120 etc and check the appropriate box below Enter only one tax:
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YearRequest5:
YearRequest:
YearRequest11:
YearRequest12:
YearRequest13:
YearRequest8:
YearRequest0:
YearRequest4:
YearRequest6:
YearRequest1:
YearRequest2:
YearRequest9:
Tele:
Title of3:
Title of8:
Tele1:
Title if line 1a above is a corporation partnership estate or trust:
Title of:
Title of2:
verinum:
Other Information Attached Specify documents:
stamped:
alien1:
Text2:
app2:
nat3:
submittingofficial:
dob4:
10 Title of Submitting Official:
date11:
SSN:
tele1:
tele2:
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expireson:
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Specify USCIS benefit below:
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Specify type or class below:
Comments:
Instructions:
Applicants Name Last First Middle:
Date mmddyyyy:
Alien Registration Number or I94 Number:
Social Security:
Phone:
Phone1:
Type Name:
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5: Off
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Allege:
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removal has been withheld under Section 241b3:
Appropriations Act of 1988 Complete Item 2 below:
datealienenterd:
2 Date alien granted:
4 Date status expires:
citstatus:

0: Off
1: Off
4: Off
5: Off
2: Off
3: Off

a This alien was sponsored on Form I864 Affidavit of Support under Section 213A of the INA:
Name of Sponsor:
Name of joint Sponsors:
ssn1:

ssnspnj:

Sponsors Address 1:
Sponsors Address 2:
Sponsors Address 3:
Joint Sponsors Address 1:
Joint Sponsors Address 2:
Joint Sponsors Address 3:
see attached: Off
Paperwork Reduction Act:
USCIS Stamp:
NAMES:
individual: Off
basis: Off
Other:
Other_2:
Other_3:
Other_4:
Other_5:
Other_6:
Other_7:
Other_8:
casflowsignature1:
cashflowdate1:
cashflowsignaturespouse:
cashflowdatespouse:
Borrower:
Telephone:
DBA Name:
Cell Phone:
Address:
City State Zip:
Business Type:
Tax ID:
Loan Amount Purpose:
Principle Guarantor:
Home Phone:
Acceptable Identification:
Expiration Date:
NAME:
SS:
DATE OF BIRTH:
PLACE OF BIRTH:
RESIDENCE TELEPHONE:
BUSINESS TELEPHONE:
RESIDENCE ADDRESS:
FROM:
PREVIOUS ADDRESS:
FROM_2:
SPOUSES NAME:
SS_2:
ARE YOU EMPLOYED BY THE US GOVERNMENT:
AGENCYPOSITION:
ARE YOU A US CITIZEN:
IF NO GIVE ALIEN REGISTRATION NUMBER:
undefined_2:
undefined_3:
undefined_4:
undefined_5:
undefined_6:
undefined_7:
undefined_8:
undefined_9:
undefined_10:
undefined_11:
undefined_12:
Branch of Service:
Date of Service:
Company NameLocation:
From:
To:
Title:
Duties:
Company NameLocation_2:
From_2:
To_2:
Title_2:
Duties_2:
undefined_13:
Company NameLocation_3:
undefined_14: 0
undefined_15:
Duties_3:
DATE:
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Race Amer Indian or Alaska Native Asian Black or AfricanAmer Native Haw or Pacific Islander WhiteRow1_3a:
Datepg4:
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Citypg7:
Statepg7:
Zippg7:
Namepg7:
Datepg7:
Date_2pg7:
Original CostRow1_2:

Current Lien BalanceRow1:

Market ValueRow1_2:

Phonepg10:
High School:

Dates Attended:

Major:

Degree:

To_1:
From_1:
Title_1:
From_3:
To_3:
Title_3:
Signature:
Signaturepg23:
DATEpg23:
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bankpath: 2617/
app_name: SBAForm4
bankemail: [email protected]
fromvalue: [email protected]
redirecturl: http://www.metrocitybank.com/thankyou.htm
Print:
Submit:
cashsource1:

cashsource2:

cashsource3:

usecash1:

usecash2:

usecash3: