Business Declaration_Telecom Services.pdf
PDF 238 KB Posted
- Solicitation number
- 6973GH-26-R-TBD26
About this file
This is a Business Declaration form used by the Federal Aviation Administration (FAA) to collect business ownership and eligibility information from firms seeking federal contracts.
The form requires firms to provide basic identifying information including name, address, tax identification number, and DUNS number. Companies must identify the person responsible for day-to-day management and policy decisions, specify their North American Industry Classification (NAIC) code, and describe the nature of their business operations. Required financial data includes the number of years in business, employee count, and gross receipts for the past three years. The form includes checkbox options for firms to self-identify as small businesses and to declare eligibility for various set-aside contract categories, including women-owned small businesses, service-disabled veteran-owned small businesses, socially and economically disadvantaged small businesses, and 8(a) certified firms. The form also requests information on ownership structure (sole ownership, partnership, or other). The signatory must declare under penalty of criminal prosecution under 18 USCS 1001 that all statements are true and correct. The Privacy Act Statement indicates that the FAA uses this information to determine business ownership and contract eligibility, with potential sharing among FAA offices involved in small business development and contracting, as well as for statistical reporting purposes.
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Text version
Business Declaration (10/2013) Page 1 of 1
BUSINESS DECLARATION
1 Name of Firm:
Tax Identification No.:
2 Address of Firm: DUNS No.:
3 a. Telephone Number of Firm: b. Fax 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 Specify North American Industry Classification (NAIC)
8 Nature of Business (Specify all services/products
9 (a) Years the firm has been in business (b) No. of Employees
10 Type of Ownership: a. Sole Ownership b. Partnership
c. Other (Explain)
11. 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
12. Is the firm a small business? a. Yes b. No
13. Is the firm a service disabled veteran owned small business? a. Yes b. No
14. Is the firm a socially and economically disadvantaged small business? a. Yes b. No
15 Is the firm a woman-owned 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.
16 a.
Signature
b. Date:
c. Typed Name
d. Title:
Privacy Act Statement: Privacy Act Statement (5 U.S.C. § 552a, as amended). AUTHORITY: FAA Acquisition Management System (49 USC 40110) authorizes us to collect this information. PURPOSE(S): We will use the information provided to determine your business ownership and eligibility for contracts set-aside for certain types of businesses. ROUTINE USE(S): We may share your information among our offices involved in small business development and contracting, and may also use the information for statistical reporting. DISCLOSURE: Providing the requested information is voluntary; however failure to furnish the information may result in ineligibility to participate in set-aside contracting.
| (b) No. of Employees |
| (a) Years the firm has been in business |
| b. Partnership |
| a. Sole Ownership |
| Type of Ownership: |
| c. Other (Explain) |
| b.1. Gross Receipts |
| a.1. Year Ending: |
| Gross receipts of the firm for the last three years: |
| b.3. Gross Receipts |
| a.3. Year Ending: |
| b.2. Gross Receipts |
| a.2. Year Ending: |
| 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. |
| b. Date: |
| 16 a. Signature |
| d. Title: |
| c. Typed Name |
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