The holder of each option shall be identified in column (1). The number of shares optioned shall be shown in column (2). In column (3) shall be described the type and class of stock called for by the option, such as common-$5 par, preferred (7 percent Series of 1969), etc. Column (4) shall show the grant and expiration dates of each option and column (5) shall set forth the price or prices at which each option is exercisable, together with the period during which each price applies. Column (6) shall show the fair market value, per share, of stock called for by each option, at the date the option was granted. The price at which the option is exercisable as a percentage of fair market value, per share, of the optioned stock at date of granting shall be shown in column (7). Column (8) shall set forth the provisions made with respect to each option in the event of the optionee's death or retirement, or other circumstances. The fair market value, per share, of stock called for at date the option was granted, if not ascertainable on the basis of actual market, shall be as determined by the board of directors. SCHEDULE 16-SHAREHOLDERS, OFFICERS, AND DIRECTORS OF THE LICENSEE Furnish in this schedule the information as required by the form regarding equity securities issued by the Licensee and regarding the Licensee's officers, directors, and manager. In column (1) list: (a) Each person or company directly or indirectly owning, controlling, or holding with power to vote, 5 percent or more of the outstanding voting securities of the company. (b) Each person or company owning of record or being known to own beneficially more than 10 percent of any other class of equity securities of the company. (c) Each officer, director, or manager of the SBIC. (List and identify all officers and directors, and manager regardless of whether or not they own any equity securities of the company.) Show in column (2) whether each natural person listed in column (1) is an officer, director, manager of the Licensee or specific combination of any of the three and the total renumeration for the period received by each from the Licensee. Indicate in column (3) the type of business in which each listed person or company is engaged. Column (4) shall show the title of each class of stock owned by any person or company and column (5) shall indicate whether the securities of the specific class are owned both of record and beneficially, of record only, or beneficially only. In columns (6), (7), and (8), respectively, show the number of shares of each class owned by each listed person or company, the total par or stated value of such shares, and the percentage of the total number of shares of this class outstanding which is repre sented by the shares owned by the particular person or company. Summarize the foregoing information by class of equity security at the bottom of the schedule. SCHEDULE 17-SUNDRY ASSETS Show and explain in this schedule, by appropriate classification, the amounts of all sundry assets. Such assets will include: (1) Notes receivable; (2) accounts receivable, including dividends receivable; (3) accrued interest receivable; (4) funds in escrow pending closing of financing, and prepayments or deferred charges; and (5) unamortized organization costs. Identify each item and describe the transaction out of which it arose, giving names of debtors and terms of debt instruments. SCHEDULE 18-LOANS AND INVESTMENTS AND ACTUAL LOSS EXPERIENCE THEREON Furnish in this schedule the total principal amounts classified between venture capital and nonventure capital as defined under § 107.3 of this regulation of all loans and investments originating during the fiscal year and any actual principal lost on any loans and investments during the fiscal year entered in the following categories: (1) Notes and Accounts Receivable (includes accrued interest receivable and amounts due from debtors on sale of assets acquired in liquidation), (2) Loans (section 305), (3) Debt Securities (section 304), and (4) Capital Stock. Also furnish in this schedule the average months elapsed between the date of the loan or investment and its final disposition for all categories except notes and accounts receivable. See more detailed instructions printed on the schedule. VERIFICATION OF THE FINANCIAL REPORT, SBA FORM 468 The verification of the Financial Report, SBA Form 468, shall bear the signature of the chief financial officer of the Licensee, or other officer authorized by the board of directors to sign in the event the chief financial officer is unavailable. A secretarial officer of the Licensee shall attest by signature to the fact that the minutes of a meeting of the board of directors show that the Financial Report, SBA Form 468, has been reviewed and approved by the board of directors. The date on which each signature is affixed shall be shown. All signatures on all copies of the Financial Report, SBA Form 468, submitted to SBA shall be original signatures in ink. a secretarial officer of the Licensee attesting to the fact that the minutes of a meeting of the board of directors show that such statement has been reviewed and approved by the board of directors. The date on which such signature is affixed shall be shown. The secretarial officer's signature on all copies of the Licensee's statement concerning prospects for divestiture of control submitted to SBA shall be an original signature in ink. [Amdt. 5, 35 F.R. 4597, Mar. 14, 1970] APPENDIX 3-INSTRUCTIONS FOR PREPARATION OF THE PROGRAM EVALUATION REPORT, SBA FORM 684 (3-70) Section 107.1102 (f) of the regulations governing small business investment companies includes a provision requiring each Licensee to submit a Program Evaluation Report, SBA Form 684, as of March 31 of each year. The report is required to be filed with the Small Business Administration on or before June 30 of the same calendar year. Three executed copies of the report shall be furnished to SBA. Each such report as of March 31 shall reflect all Licensee financing of small business concerns which were outstanding at any time during the preceding 12-month period. In the instance of financing terminated during the year, it is necessary that the financing be reported with the proper status code. If the Licensee has engaged in more than öne financing of a single small business concern (for example: two loans made at different times evidenced by separate financing instruments, or one loan, one debt security with warrants, and one purchase of capital stock of the SBC), the most recent financing shall be entered in the left-most column of the form. Make the appropriate entry opposite each numbered line for the last such financing, and make entries only on lines 9 through 14 on the right side of the form for previous and other financings of the same small business concern which were outstanding at any time during the preceding 12-month period. Multiple disbursements under a single fi. nancing agreement to a small business concern are to be treated as one financing, and only one entry shall be made on line 12 to include all such disbursements to the small business concern. If as of the date of this report the total amount of the financing provided for in a multiple-disbursement agreement has not yet been fully disbursed, the total financing provided for in the agreement shall be entered on line 12, rather than the amount actually disbursed. Except as noted above with respect to more than one financing of a single small business concern, entries shall be made in the report on each line (1 through 35) for each financing outstanding at any time during the 12-month period ended March 31. In entering financings in which participation by others is a factor, an "initiating" Licensee shall show on line 12 only its own share of total funds disbursed (net of participations sold), and a Licensee which has purchased a participation shall enter on line 12 the amount represented by its participation in total funds disbursed. Both the "initiating" company and the "participating" company shall complete all lines (1 through 35) of the report for such financings. A participation is defined as an undivided interest shared with one or more other lenders or investors in a note, debenture, certificate of stock, or other instrument evidencing a loan to, or equity financing of, a small business concern. The spaces for license number and name of Licensee, and lines 1 through 14 and 24 through 34 must be filled out in each year's report. Lines 15 through 23 are required to be filled out only if the specific information called for has not been furnished in a prior report. Line 35, if applicable, should be filled out only once for any one small business concern. If the "current information," represented by entries on lines 24 through 34 is either impossible to obtain or misleading with respect to small business concerns which (a) have been merged into other companies since the financing, (b) are presently inactive, or (c) are insolvent, the Licensee may write the word "merged," "inactive," or "insolvent," as appropriate, on lines 24 through 34 rather than make detailed entries for these items. Entries of all dollar amounts shall be rounded to the nearest dollar. Instructions covering each line of the report are as follows: A. Entries to be made on each page of the report: Page number, and total number of pages in the report. (Examples: Page 1 of 4 pages, or page 3 of 6 pages.) 2. Employer identification number of the small business concern (SBC) financed. The small business concern will have an employer identification number or must obtain one by filing Form SS-4 with the U.S. Director of Internal Revenue for the area in which it is located. 3. City. Enter the city in which the small business concern's principal office is located. 4. County. Enter the county in which the small business concern's principal office is located. 5. State. Enter the state in which the small business concern's principal office is located. 6. SIC. Enter the four-digit Standard Industrial Classification Code of the principal industry in which the small business concern is engaged. Determine the roper code by reference to the Standard Industrial Classification Manual, issued by the Executive Office of the President, Bureau of the Budget. 7. Date business established. Enter the month and year that the small business concern commenced business in its present form. 8. Form of business. Show whether the filnanced concern is a corporation, partnership, proprietorship, etc. 9. Type of investment. Types of investment include loans, debt securities, capital stock, and stock rights (including warrants or options). 10. Financing number. If the Licensee has had more than one financing of the same type outstanding with the same small business concern, each such financing shall be entered in the form in the manner described in the third paragraph of this appendix. Each similar financing shall be assigned a financing number for purposes of identification, and this financing number shall be shown on future reports setting forth the same financing. Each type of investment should be numbered sequentially. As an example, loans would be numbered 1, 2, 3; debt security 1, etc. 11. Initial disbursement date. Enter the date of the first disbursement applicable to the specific financing made to the small business concern. 12. Total funds disbursed. Show the total amount of funds disbursed, including the amount of any discount, fees, and other charges, to the small business concern applicable to each specific financing. Refer to the fourth paragraph of this appendix for instruction regarding the treatment of multiple disbursements under a single financing agreement to a small business concern. 13. Use of proceeds (code). Enter the code number indicating which of the following was the primary purpose of the small business concern in obtaining the financing. If it had multiple purposes, select the single most important purpose. Enter only one code number for each financing: Operating capital (Code No. 1). Plant modernization (Code No. 2). Acquisition of all or part of an existing business (Code No. 3). Consolidation of obligations, debt refunding, etc. (Code No. 4). New building or plant construction (Code No. 5). Acquisition of machinery and equipment (Code No. 6). Land acquisition (Code No. 7). 14. Status of financing (code). Enter the appropriate code number to indicate the current status of the financing: Repayment or other investment recovery of the full amount of principal and interest or cost of other investment appears to be reasonably assured (Code No. 1). Repayment or other investment recovery of the full amount of principal and interest or cost of other investment is possible, but not assured pending improvement in the performance of the small business concern financed (Code No. 2). Repayment or other investment recovery is in jeopardy and some loss is probable (Code No. 3). The financing has been paid off in full by the financed small business concern or has been disposed of otherwise at cost or at a profit to the Licensee (Code No. 4). The financing has been liquidated through sale, partial repayment and writeoff, or foreclosure, and Licensee has either absorbed a loss on the financing or may absorb a loss in the future when collateral is liquidated (Code No. 5). The financing instrument was exchanged for another financing instrument of the same small business concern prior to the reporting date (Code No. 6). NOTE: The new financing instrument should be reflected in entries elsewhere in the report. The financing instrument was exchanged through merger, etc., for a financing instrument of a different business concern prior to the reporting date (Code No. 7). NOTE: The new financing instrument, if considered to evidence financing of an eligible small business concern, should be reflected in entries elsewhere in the report. 15 and 24. Fiscal year ended immediately prior to financing (date) and latest fiscal year ended (date). Enter the date of the close of the financed small business concern's latest fiscal year which ended prior to the initial date of disbursement of funds related to the financing (line 15) and the date of the close of the financed concern's most recently completed fiscal year for which amounts are entered in the current information section of the report (line 24). If current fiscal year information is not available from the small business concern, enter the date of the close of the financed concern's latest fiscal year for which information is available, and enter such information on the appropriate lines of the current information section of the report. The respective fiscal years ended on the dates shown on lines 15 and 24 are the ones referred to in the following instructions for lines 16 and 25, 17 and 26, 18 and 27, 19 and 29, 20 and 30, 21 and 31, 22 and 32, and 23 and 33. The fiscal year ended on the date shown on line 24 is the one referred to in the following instructions for line 28. 16 and 25. Number of employees: Total. Enter the financed small business concern's total number of employees at the close of the respective fiscal years. 16 and 25. Number of employees: Managerial. Enter the financed small business concern's number of managerial employees at the close of the respective fiscal years. Man agerial employees are administrative personnel who set broad policies, exercise overall responsibility for execution of these policies, and direct individual departments or special phases of a firm's operations. They include executives, middle management, plant managers, department managers and superintendents, salaried foremen who are members of management, purchasing agents and buyers, and kindred workers. 16 and 25. Number of employees: Skilled. Enter the financed small business concern's number of skilled employees at the close of the respective fiscal years. Skilled employees include professional workers, technicians, sales representatives, office and clerical workers, and craftsmen (manual workers of relatively high skill level who exercise considerable independent judgment and usually receive an extensive period of training). 16 and 25. Number of employees: Unskilled and semiskilled. Enter the financed small business concern's number of unskilled and semiskilled employees at the close of the respective fiscal years. Unskilled employees are laborers in manual occupations which generally require no special training and embrace elementary duties that may be learned in a few days and require the application of little or no independent judgment. Semiskilled employees are workers who operate machines or processing equipment or perform other duties of intermediate skill level which can be mastered in a few weeks and require only limited training. 17 and 26. Gross revenue for the year. Enter the amount of total sales or other gross revenues of the financed small business concern for the respective fiscal years. 18 and 27. Profit or (loss) for the year. Enter the amount of net profit or (loss), before taxes, of the financed small business concern for the respective fiscal years. In determining profit or loss for the year, disregard any loss carryovers from previous years. 28. Corporate dividends for the year. Enter the total amount of dividends declared by the financed small business concern to its stockholders during the fiscal year. If the small business concern is not a corporation, enter "N/A" (not applicable). 19 and 29. Taxes for the year: Federal. Enter the amount of Federal income and other taxes applicable to the financed small business concern for the respective fiscal years, but not including taxes withheld or collected from others or the employer's portion of social security and unemployment taxes. 19 and 29. Taxes for the year: State. Enter the amount of State income and other taxes applicable to the financed small business concern for the respective fiscal years, but not including taxes withheld or collected from others or the employer's portion of unemployment taxes. 19 and 29. Taxes for the year: Local. Enter the amount of local income and other taxes (including property taxes) applicable to the financed small business concern for the re spective fiscal years, but not including taxes withheld or collected from others. 20 and 30. Total assets. Enter the total amount of all assets, but net of valuation reserves, held by the financed small business concern as of the close of the respective fiscal years. 21 and 31. Net worth (deficit). Enter the amount of the net worth or (deficit net worth) of the financed small business concern as of the close of the respective fiscal years. 22 and 32. Retained earnings (deficit). Enter the amount of the retained earnings or (retained earnings deficit) of the financed small business concern as of the close of the respective fiscal years. 23 and 33. Borrowing: Short-term. Enter that portion of the financed small business concern's outstanding borrowing which was due within 1 year from the close of the respective fiscal years. This entry shall cover fund borrowing of all types, such as bank loans, mortgages, amounts borrowed from SBICS, etc. 23 and 33. Borrowing: Long-term. Enter that portion of the financed small business concern's outstanding borrowing which was due after 1 year from the close of the respective fiscal years. This entry shall cover borrowing of all types, such as bank loans, mortgages, amounts borrowed from SBICS, etc. 34. Stock registered (Yes or No). Indicate by "yes" or "no" whether or not any of the presently issued and outstanding stock of the financed small business concern has been registered with the Securities and Exchange Commission under the Securities Act of 1933. (For this purpose a filing under Regulation A of SEC shall be considered a registration.) If the small business concern is not a corporation, enter "N/A" (not applicable). 35. SBC discontinuances (code). If the financed small business concern has discontinued business during the period covered by the report, enter the code number designating the reason for its discontinuance. If the concern has not discontinued business, enter "N/A" (not applicable). Enter only one code or "N/A" for each financed small business concern. 1). Discontinuance codes are: Insolvency and/or bankruptcy (Code No. Merger with, or sale to, another business concern, the resulting firm being eligible for further SBIC financing (Code No. 2). Merger with, or sale to, another business concern, the resulting firm not being eligible for further SBIC financing (Code No. 3). Voluntary liquidation, for reasons such as retirement of concern's principal (Code No. 4). Involuntary liquidation, for reasons other than insolvency such as fire, death of a principal, or condemnation of business location (Code No. 5). Other causes (Code No. 6). (a) As part of the congressional policy to improve and stimulate the national economy in general, and the small-business segment thereof in particular, by establishing a program to stimulate the flow of private equity capital and longterm loans for the sound financing of the operations, growth, expansion, and modernization of small-business concerns, the Small Business Administration is authorized to make loans to State and local development companies which will further that policy. This policy shall be carried out in such manner as to insure the maximum participation of private financing sources. No such loan shall be made if the effect thereof will be to cause a substantial increase of unemployment in any area of the country. (b) The Government of the United States has declared that no person in the United States shall, on the grounds of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance. (Title VI of the Civil Rights Act of 1964.) The President of the United States has also declared in Executive Orders No. 10925 of March 6, 1961 (26 F.R. 1977), and No. 11114 of June 23, 1963 (28 F.R. 6485), that all qualified persons should be given equal employment opportunity without regard to race, color, creed, or national origin, when employed or seeking employment with Government contractors or with contractors performing under federally assisted construction contracts. Recipients of financial assistance under this part are subject to the nondiscrimination requirements of the laws and policies referred to in this section. For purposes of this part: (a) "Administrator" means the Administrator of the Small Business Administration. (b) "SBA" means the Small Business Administration. (c) "Small-business concern" means a business concern which would qualify as a small business under § 121.3-10 or § 121.3-11 of this chapter. (d) "Development company" means an enterprise incorporated under the laws of one of the several States, formed for the purpose of furthering the economic development of its community and environs, and with authority to promote and assist the growth and development of small-business concerns in the areas covered by their operations. Such corporation may be organized either as a profit or nonprofit enterprise. (1) A State development company is a corporation organized under or pursuant to a special legislative act to operate on a statewide basis. (2) A local development company is a corporation chartered under any applicable State corporation law to operate in a specified area within a State. A local development company shall be principally composed of and controlled by persons residing or doing business in the locality; such local persons shall ordinarily constitute not less than 75 percent of the voting control of the development company. No shareholder or member of the development company may own in excess |