BY SIGNING, I REQUEST SERVICES FROM THE ENTREPRENEUR FUND (EF), A SMALL BUSINESS ADMINISTRATION (SBA) RESOURCE PARTNER:
I understand information disclosed will be held in strict confidence; EF/SBA will not provide personal information to commercial entities.
I agree to participate in program surveys that evaluate EF/SBA services. I authorize EF/SBA to furnish relevant information to assigned staff.
I understand the advising staff will not:
Information provided is used to report to funders, many who require that the EF serve specific populations. I understand for some programs and services, I will need to furnish EF with personal, household and business income to satisfy funder requirements. I certify that information regarding my income is accurate and complete. I authorize EF to verify the income information provided and share with funders for reporting purposes.
Warning (SBA): Section 1001 of Title 18 of the United States Code (Criminal Code and Criminal Procedure) shall apply to the foregoing certification. Title 18, provides among other things, that whoever, knowingly and willingly makes or uses a document or writing containing any false, fictitious or fraudulent statement or entry, in any manner within the jurisdiction of any department or agency of the United States, shall be fined not more than $10,000 or imprisoned not more than five years, or both.
Note: The estimated burden for completing this form is 18 minutes. You are not required to respond to any collection information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to: US Small Business Administration, 409 3rd St, SW, Washington, DC 20416, and to: Desk Officer SBA, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, DC, 20503. OMB Approval (3245-0324). PLEASE DO NOT SEND FORMS TO OMB.
The Entrepreneur Fund (EF) is an equal opportunity employer, lender, & service provider. EF does not discriminate in providing services on the basis of race, color, religion, sex, national origin, age, marital status, family status, physical or mental disabilities. Reasonable accommodations for people with disabilities or with limited English proficiency are available upon request. Make requests at least 2 weeks in advance by contacting our office at 218-623-5747 or firstname.lastname@example.org.