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SIR NO. 693KA9-19-R-00028 Attachment J-4 Business Declaration Form Attachment J-4 Business Declaration Form
| 3. |
| Telephone Number of Firm: |
| 4. |
| a. Name of Person Making Declaration |
| b. Telephone Number of Person Making Declaration |
| c. Position Held in the Company |
| 5. |
| Controlling Interest in Company (“X” all appropriate boxes) |
|_| a. Black American |_| b. Hispanic American |_| c. Native American |_| d. Asian American
| |_| e. Other Minority (Specify) |
| |_| f. Other (Specify) |
|_| g. Female |_| h. Male |_| i. 8(a) Certified (Certification letter attached) |_| j. Service Disabled Veteran Small Business
| 6. |
| Is the person identified in Number 4 above, responsible for day-to-day management and policy decision making, including but not limited to financial and management decisions? |
|_| a. Yes |_| b. No (If “NO,” provide the name and telephone number of the person who has this authority.)
| 7. |
| Nature of Business (Specify all services/ products (NAIC)) |
| 8. |
| (a) Years the firm has been in business: |
| (b) No. of Employees |
| 9. |
| Type of Ownership: |
| |_| a. Sole Ownership |
| |_| b. Partnership |
| 10. |
| Gross receipts of the firm for the last three years: |
| a.1. Year Ending: |
| b.1. Gross Receipts |
| a.2. Year Ending: |
| b.2. Gross Receipts |
| a.3. Year Ending: |
| b.3. Gross Receipts |
| 11. | | |
| Is the firm a small business? | |_| a. Yes | |_| b. No |
| 12. | |
| Is the firm a service disabled veteran owned small business? |_| a. Yes | |_| b. No |
| 13. | |
| Is the firm a socially and economically disadvantaged small business? |_| a. Yes | |_| b. No |
| I DECLARE THAT THE FOREGOING STATEMENTS CONCERNING |
ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION, AND BELIEF. I AM AWARE THAT I AM SUBJECT TO CRIMINAL PROSECUTION UNDER THE PROVISIONS OF 18 USCS 1001.
| 14. a. Signature |
| b. Date: |
