• PERSONAL FINANCIAL STATEMENT

    Women-Owned Small Business Federal Contract Program

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  • All information provided within this form is accurate as of:*
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    2 digit month, 2 digit day, 4 digit year

  • U.S. SMALL BUSINESS ADMINISTRATION

    • Each individual claiming economic disadvantage must submit personal financial information.
    • When married, an individual claiming economic disadvantage must submit separate financial information for his or her spouse, unless the individual and the spouse are legally separated.
    • Additionally, any proprietor; partner; member of a limited liability company (LLC); or owner of 10% or more of the equity of the business MUST complete this form.

    Note: Please complete this form with Personal Information -- not Business information.

  • PERSONAL INFORMATION SECTION

    Provide your personal information.

  • ASSETS

    Provide in dollars. Omit cents.
  • Details: Stocks, Bonds and Mutual Funds. Use attachments if necessary. Each attachment must be identified as part of this statement and signed*
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  • Details: Real Estate Owned. List each parcel separately. Use attachment if necessary. Each attachment must be identified as a part of this statement and signed*
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  • LIABILITIES

    Provide in dollars. Omit cents.
  • Details: Notes Payable to Banks and Others.
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  • IMPORTANT: The two fields below should have the exact same total.

    Your "Total Liabilities & Networth" should equal your "Total Assets."

  • SOURCE OF INCOME

    Provide in dollars. Omit cents.

  • CONTINGENT LIABILITIES

    Provide in dollars. Omit cents.

  • AUTHORIZATION AND SIGNATURE

    Penalties and Administrative Remedies for False Statements also apply to the EDWOSB Program.

  • I authorize the SBA to make inquiries as necessary to verify the accuracy of the statements. CERTIFICATION: (to be completed by person submitting the information requested on this form)

    By signing this form, I certify under penalty of criminal prosecution that all information on this form and any additional supporting information submitted with this form is true and complete to the best of my knowledge. I understand that SBA will rely on this information when making decisions regarding an application for participation in the Women-Owned Small Business Federal Contract Program Program.

  • NOTICE TO APPLICANTS OR PARTICIPANTS IN THE 8(a) BD PROGRAM: CRIMINAL PENALTIES AND ADMINISTRATIVE REMEDIES FOR FALSE STATEMENTS

  • Any person who misrepresents a business concern’s status as an 8(a) BD Program participant or SDB concern (or EDWOSB), or makes any other false statement in order to influence the 8(a) certification (or EDWOSB) or other review process in any way(e.g., annual review, eligibility review), shall be: (1) subject to fines and imprisonment of up to 5 years, or both, as stated in Title 18 U.S.C. § 1001; (2) subject to fines of up to $500,000 or imprisonment of up to 10 years, or both, as stated in Title 15 U.S.C. § 645; (3) subject to treble damages and civil penalties under the False Claims Act, 31 U.S..C 3729; (4) subject to administrative remedies, including suspension and debarment; and (5) ineligible for participation in programs conducted under the authority of the Small Business Act.

  • Date of Signature*
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    2 digit month, 2 digit day, 4 digit year

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