812C_CUF_Declaration_(1).pdf

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POST Certified Transcriber
Solicitation number
0000035598
Issued by
Yolo County, California

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This document is a California Department of General Services (DGS) Small Business & Disabled Veteran Business Enterprise (DVBE) Applicant or Certified Firm Declaration form (Form 812C, Revised 12/2012). The form requires businesses seeking small business or DVBE certification to provide several key declarations under penalty of perjury, including confirming the accuracy of application information, acknowledging potential federal tax return transcript requests, and certifying that a Commercially Useful Function (CUF) will be performed on state contracts.

The form specifically requires applicants, particularly those seeking Disabled Veteran Business Enterprise status, to validate ownership and operational details. For DVBE applicants, there is a specific requirement to demonstrate that at least 51% of stock or voting stock is unconditionally owned by one or more disabled veterans. The document provides space for multiple owners, corporate officers, or managers to sign and date the declaration, indicating organizational commitment to the stated representations. The form is administered by the Office of Small Business & DVBE Services, located in West Sacramento, California, with contact information provided for further inquiries.

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SB/DVBE APPLICANT OR CERTIFIED FIRM PENALTY OF PERJURY DECLARATION

SB/DVBE FEDERAL TAX RETURN TRANSCRIPT ACKNOWLEDGEMENT

COMMERCIALLY USEFUL FUNCTION (CUF) DECLARATION

DISABLED VETERAN (DV) 51% UNCONDITIONAL OWNERSHIP ACKNOWLEDGEMENT

812C (Rev 12/2012)

Office of Small Business & DVBE Services 707 3rd Street, 1st Floor, Ro om 1-400, MS 210 West Sacramento, CA 95605 http://www.dgs.ca.gov/pd/Programs/OSDS.aspx ▪ (916) 375-4940 ▪ (916) 375-4950 FAX

PENALTY OF PERJURY DECLARATION (Part 1)

The undersigned states:

I certify (or declare) under penalty of perjury under the laws of the State of California that all information submitted in the Small Business and/or the Disabled Veteran Business Enterprise (DVBE) application, and any additional information to determine eligibility, is true and correct.

FEDERAL TAX RETURN TRANSCRIPT ACKNOWLEDGEMENT (Part 2)

The undersigned acknowledges that upon request by the Department of General Services, Office of Small Business & DVBE Services, that the Small Business or DVBE, applicant or certified firm, must submit a specified federal tax form to release transcripts of tax returns.

COMMERCIALLY USEFUL FUNCTION (CUF) DECLARATION (Part 3)

I/We certify (or declare) that a Commercially Useful Function (CUF) will be performed on each state contract.

DV 51% UNCONDITIONAL OWNERSHIP ACKNOWLEDGEMENT (Part 4)

Only applicable to DVBE applicants:

The undersigned acknowledges that applicants or certified firms must submit documents requested by the Department of General Services, Office of Small Business & DVBE Services, that establish at least 51% of the stock or voting stock be unconditionally owned by one or more disabled veterans.

Authorized signature from each Owner, Corporate Officer, Member/Manager OWNER’S OR CORPORATE OFFICER’S SIGNATURE OWNER’S OR CORPORATE OFFICER’S PRINTED NAME DATE

OWNER’S OR CORPORATE OFFICER’S SIGNATURE OWNER’S OR CORPORATE OFFICER’S PRINTED NAME DATE

OWNER’S OR CORPORATE OFFICER’S SIGNATURE OWNER’S OR CORPORATE OFFICER’S PRINTED NAME DATE

OWNER’S OR CORPORATE OFFICER’S SIGNATURE OWNER’S OR CORPORATE OFFICER’S PRINTED NAME DATE http://www.dgs.ca.gov/pd/Programs/OSDS.aspx

OWNERS OR CORPORATE OFFICERS PRINTED NAME:
DATE:
OWNERS OR CORPORATE OFFICERS PRINTED NAME_2:
DATE_2:
OWNERS OR CORPORATE OFFICERS PRINTED NAME_3:
DATE_3:
OWNERS OR CORPORATE OFFICERS PRINTED NAME_4:
DATE_4:

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