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This document is a Commercially Useful Function (CUF) Certification Form issued by the State of California Department of Veterans Affairs for solicitation number 25FS0032. The form is designed for certified Small Businesses (SB), Micro Businesses (MB), and Disabled Veteran Business Enterprises (DVBE) to demonstrate their ability to perform a distinct and meaningful role in a potential contract. The form requires businesses to certify that they will be responsible for executing a specific element of work, carry out contract obligations by performing, managing, or supervising the work, and perform work that is normal for their business functions.

The form includes a series of yes/no questions that assess the company's capability to provide a commercially useful function, with specific guidelines to prevent pass-through entities or businesses that would subcontract an unusually large portion of work. Businesses must provide a written statement detailing their proposed role, services, and goods to meet the commercially useful function requirement. The form must be signed by an authorized representative who certifies under penalty of perjury that the information provided is truthful and accurate. Negative responses to key questions or affirmative responses to questions about excessive subcontracting may result in the quote being deemed non-responsive and disqualified.

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State of California Department of Veterans Affairs

COMMERCIALLY USEFUL FUNCTION (CUF) CERTIFICATION FORM

CV 012 (REV. 08/2023) 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. 08/2023) 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. 08/2023) 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. 08/2023) 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.

9.0.0.2.20101008.1.734229

SolicitationNumber: 25FS0032
DoingBusinessAs:
OSDSRefNumber:
ExpirationDate:
:
Yes:
No:
ProvideAWrittenStatement:
AuthorizedRepresentative:
Title:
PrintedName:
Date:

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