Attachment 11 Business Declaration Form 250918.pdf
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- Solicitation number
- FMDS-2025-ChBA
About this file
This document is a Business Declaration form (FAA Template No. 61) used to collect comprehensive business and ownership information. The form requires detailed company details including firm name, address, contact information, ownership characteristics, business nature, and key organizational attributes. Significant sections include identifying controlling business interests (such as minority status, gender, veteran-owned business certification), verifying day-to-day management responsibilities, documenting business type, years in operation, number of employees, and gross receipts. The form also requests self-certification regarding small business status, service-disabled veteran ownership, and socially/economically disadvantaged business classification. The declarant must sign under penalty of potential criminal prosecution, affirming the accuracy of provided information.
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Text version
OMB Control No. 2120-0595 FAA Template No. 61 (rev. 10/03)
BUSINESS DECLARATION
1. Name of Firm:
Tax Identification No.:
2. Address of Firm:
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
c. Other (Explain)
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 R i 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:
c. Typed Name d.
Title:
| (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: |
| 14. a. Signature |
| d. Title: |
| c. Typed Name |
File details come from the government source that posted it. Updated .