Attachment 8.4 - Business Declaration.docx

DOCX document 21 KB Posted

Attached to
MDR Maintenance Display Replacement
Solicitation number
693KA7
Issued by

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This document is a business declaration form required for the federal contract opportunity solicitation number 693KA7 for MDR Maintenance Display Replacement managed by the Department of Transportation Federal Aviation Administration Enroute Terminal Contracts. The business declaration collects information on the contracting firm's ownership status, years in business, number of employees, gross receipts for the past three years, and certifications including status as a small, veteran-owned, or socially and economically disadvantaged small business. The declaration requires the signature of an authorized firm representative to attest to the accuracy of the information provided.

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BUSINESS DECLARATION

1
Name of Firm:
Tax Identification No.:

OMB Control No. 2120-0595 FAA Template No. 61 (rev. 10/08)

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
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 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:
c. Typed Name
d. Title:

File details come from the government source that posted it. Updated .