Attachment 7 - Business Declaration Form.pdf

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FAA Request for Information (RFI) Alaska Automation Capability (AAC) Challenge Based
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693KA7-26-RFI_AACCB
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This is an FAA Business Declaration Form (FAA Template No. 61) used to collect information about firms seeking federal contracting opportunities with the Federal Aviation Administration.

The form requires firms to provide basic identification information including company name, tax identification number, address, and telephone number. It requests details about the person making the declaration, including their name, telephone number, and position within the company, along with confirmation of their responsibility for day-to-day management and policy decisions. The form includes checkboxes for identifying the controlling interest in the company, with options for various minority classifications (Black American, Hispanic American, Native American, Asian American, Other Minority), gender (Female, Male), and special business designations (8(a) Certified, Service Disabled Veteran Small Business). Additional required information includes the nature of business using NAIC codes, years in business, number of employees, type of ownership structure, and gross receipts for the last three years. The form requires declarations regarding small business status, service-disabled veteran ownership, and socially and economically disadvantaged small business status. The declarant must sign and certify under penalty of criminal prosecution per 18 USCS 1001 that all statements are true and correct. This template is administered under OMB Control No. 2120-0595 and serves as a standardized declaration mechanism for vendor qualification and eligibility determination purposes.

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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 .