24CRY002_-_CUF_Certification_Form.pdf

State of California Department of Veterans Affairs

COMMERCIALLY USEFUL FUNCTION (CUF) CERTIFICATION FORM

CV 012 (REV. 08/2016) Page 1 of 2

Solicitation Number:

Every certified SB, MB & DVBE must complete this form if they will perform an element of the work.

1. CONTRACTOR NAME (Completing Form) "DOING BUSINESS AS" (DBA) NAME: OSDS REF # (Currently certified firms only): Expiration Date:

2. COMMERCIALLY USEFUL FUNCTIONS (CUF)

All certified Small Business, Micro Business, and/or DVBE prime contractors, subcontractors or suppliers must meet the commercially useful function requirements under Government Code, Section 14837 (d)(4) (for SB) and Military and Veterans Code, Section 999(b)(5)(B) (for DVBE).

Please answer the following questions, as they apply to your company for the goods and services being acquired in this solicitation:

Mark all that apply: DVBE Small Business Micro Business

1 If awarded a contract, will your business be responsible for the execution of a distinct element of the resulting work? Yes No

2 If awarded a contract, will your business carry out the obligation of the contract by actually performing, managing, or supervising the work involved? Yes No

3 If awarded a contract, will you perform work that is normal for your business, service and functions? Yes No

4 If awarded a contract, will your business subcontract a portion of the work greater than would be expected by normal industry practices? Yes No

5 If awarded a contract, will your business role be limited to that of an extra participant in a transaction, contract, or project through which funds are passed in order to obtain the appearance of SB and/or DVBE participation? Yes No

A response of "No" in questions 1-3 or a response of "Yes" in question 4 may result in your quote being deemed non-responsive and disqualified.

3. WRITTEN STATEMENT

Provide a written statement below detailing the role, services and goods your company will provide to meet the commercially useful function requirement. At the State's option prior to award, you may be required to submit additional clarifying information

State of California Department of Veterans Affairs

CV 012 (REV. 08/2016) Page 2 of 2

AUTHORIZING SIGNATURE (REQUIRED)

The signatory of this document must be the certified business owner (or authorized representative in the case of a corporation) and as such, hereby certifies under penalty of perjury under the laws of the State of California that all information provided herein is truthful and accurate.

AUTHORIZED REPRESENTATIVE SIGNATURE: TITLE:

PRINTED NAME: DATE:

State of California Department of Veterans Affairs

CV 012 (REV. 08/2016) Page 1 of 2 Every certified SB, MB & DVBE must complete this form if they will perform an element of the work.

1. CONTRACTOR NAME (Completing Form)

2. COMMERCIALLY USEFUL FUNCTIONS (CUF)

All certified Small Business, Micro Business, and/or DVBE prime contractors, subcontractors or suppliers must meet the commercially useful function requirements under Government Code, Section 14837 (d)(4) (for SB) and Military and Veterans Code, Section 999(b)(5)(B) (for DVBE).

Please answer the following questions, as they apply to your company for the goods and services being acquired in this solicitation:

Mark all that apply:

If awarded a contract, will your business be responsible for the execution of a distinct element of the resulting work?

If awarded a contract, will your business carry out the obligation of the contract by actually performing, managing, or supervising the work involved?

If awarded a contract, will you perform work that is normal for your business, service and functions?

If awarded a contract, will your business subcontract a portion of the work greater than would be expected by normal industry practices?

If awarded a contract, will your business role be limited to that of an extra participant in a transaction, contract, or project through which funds are passed in order to obtain the appearance of SB and/or DVBE participation?

A response of "No" in questions 1-3 or a response of "Yes" in question 4 may result in your quote being deemed non-responsive and disqualified.

3. WRITTEN STATEMENT

State of California Department of Veterans Affairs

COMMERCIALLY USEFUL FUNCTION (CUF) CERTIFICATION FORM

CV 012 (REV. 08/2016) Page 2 of 2

AUTHORIZING SIGNATURE (REQUIRED)

The signatory of this document must be the certified business owner (or authorized representative in the case of a corporation) and as such, hereby certifies under penalty of perjury under the laws of the State of California that all information provided herein is truthful and accurate.

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