Attachment B- Business_Declaration_Form.pdf
PDF 21 KB Posted
- Solicitation number
- AAQ-230RVMS-FANS25
About this file
The document is a Business Declaration form (FAA Template No. 61) used to collect comprehensive business information for a federal contract opportunity. The form requires detailed company information including firm name, address, contact details, ownership type, business nature, and demographic characteristics. Key sections include identifying the company's controlling interest (such as minority or veteran-owned status), business size, years in operation, number of employees, and gross receipts for the past three years. The form also requires a declaration of the accuracy of the information, with the signatory acknowledging potential criminal prosecution for false statements under 18 USCS 1001.
The form is specifically associated with a Federal Aviation Administration (FAA) Market Survey for Reduced Vertical Separation Minima (RVSM) for Future Air Navigation Systems (FANS), with solicitation number AAQ-230RVMS-FANS25. It is part of a pre-solicitation process seeking potential vendors to support system performance, problem resolution, and operational planning and testing for Regional Groups. The form serves as a crucial component for vendor qualification and demographic tracking in this federal contract opportunity.
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Other files
| File | Type | Posted |
|---|---|---|
| 2025 Market Survey for FANS.pdf | ||
| Attachment A-FANS Section C - SOW_2025.pdf |
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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 |
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