Attachment_D_-_Section_3_Certification_Packet_-_All_Forms.pdf

SECTION 3 - CERTIFICATION

(BUSINESS CONCERNS)

Name of Business _______________________________________________________________

Address of Business _____________________________________________________________

Phone Number: ___________________ Email: _________________________________

A. For businesses claiming Section 3 status by stating that at least 30 percent of their workforce are currently Section 3 residents or were Section 3 eligible residents within 3 years of date of first employment with the business, please provide:

A list of all current full-time employees (Please attach) List of permanent, full time employees qualified as Section 3 residents as evidenced by one of the following (Please check):

Proof of residency in a public housing development (such as a lease dated less than 3 years from date of employment)

Evidence of participation in a HUD Youthbuild program located in St. Petersburg Evidence that the employee resides in St. Petersburg and is low income (the attached self-certification can be used as evidence) Other evidence of Section 3 status less than 3 years from day of employment

OR

B. For businesses claiming Section 3 status by committing to subcontract 25 percent of the dollar awarded to qualified Section 3 businesses:

Attach a list of subcontracted Section 3 business(es) that will be used and subcontract amount

OR

C. For businesses claiming Section 3 status by stating that it is 51 percent or more owned by Section 3 residents:

Evidence that 51% or more of the ownership resides in St. Petersburg and is low income (Please attach self-certification form as evidence)

Authorizing Name and Signature Date

Print Name: _________________________________

Section 3 Resident - Income Self Certification Form

1. Name:

2. Address:

3. Total number of persons in your household: ____________

4. Please indicate the total gross income earned by all members of the household (check one):

_______ $ 0 - 11,850 _______$30,501 - 31,600 _______ 11,851 - 13,550 _______ 31,601 - 32,750 _______ 13,551 - 16,900 _______ 32,751 - 35,000 _______ 16,901 - 18,300 _______ 35,001 - 36,100 _______ 18,301 - 19,650 _______ 36,101 - 37,250 _______ 19,651 - 19,750 _______ 37,251 - 40,600 _______ 19,751 - 21,000 _______ 40,601 - 45,100 _______ 21,001 - 22,350 _______ 45,101 - 48,750 _______ 22,351 - 22,600 _______ 48,751 - 52,350 _______ 22,601 - 25,400 _______ 52,351 - 55,950 _______ 25,401 - 28,200 _______ 55,951 - 59,550 _______ 28,201 - 30,500 _______ 59,551 or more

Additional information (Optional- but appreciated):

5. Hispanic or Latino (circle one): Yes No

6. Check below:

_______ White _______ Black/African American _______ Asian _______ American Indian/Alaskan Native _______ Native Hawaiian/Other Pacific Islander

American Indian/Alaskan Native & White Asian & White Black/African American & White American Indian/Alaskan Native & Black/Af Amer Other Multi-Racial

7. Household Data (check appropriate space):

_______ Female head of household _______ Male head of household

I certify that I am the above named person that the information above is true to the best of my knowledge and belief.

Signature Date

ANY MATERIAL MISREPRESENTATION WILL BE GROUNDS FOR INITIATION ACTION

UNDER FEDERAL OR STATE LAWS CONCERNING FALSE STATEMENTS

AFFIDAVIT

Section 3 Certification

The undersigned swears (or affirms) that the foregoing statements concerning the location of the business, type of industry, annual sales volume, number of employees and other expressed criteria accurately describe the operations of my business:

(Name of Business)

Located at _____________________________________________________________________ (Physical Address) (No. & Street) (City)

(State & Zip)

Type of Industry ________________________________________________________________

Furthermore, my business also meets one the following Section 3 criteria:

Claiming Section 3 status because at least 30 percent of my workforce are currently Section 3 residents or were Section 3 eligible residents within 3 years of date of first employment with the business; or

Claiming Section 3 status by committing to subcontract 25 percent of the dollar awarded to qualified Section 3 businesses; or

Claiming Section 3 status by stating that it is 51 percent or more owned by Section 3 residents:

I understand that this affidavit affords my company Section 3 status for a period of three (3) years. Section 3 status may be revoked for the following reasons:

Revocation of Certification

Formal charges against Section 3 applicants which result in revocation of certification may be brought and adopted and Section 3 status may be revoked for either of the following reasons:

(a) Willfully making a false statement, report or other representation to a City official or employee for the purpose of obtaining Section 3 status.

(b) Willfully obstructing, impeding or attempting to obstruct or impede any City official or employee who is investigating the qualifications of a business entity that has requested Section 3 status. This may be based on any of the following non-exhaustive reasons:

1. Failure to provide sufficient information to the Business Assistance Division staff on which a determination of eligibility can be based;

2. Refusal to permit on site inspections;

3. Failure of Section 3 applicant to have been in business for at least one year.

4. Refusal to comply with a request for information, data, or access to records pertinent to the application certification.

5. Fraud or deceit in obtaining certification,

6. Failure to report changes in the status or activities of the business entity or its Section 3 status which affect the SBEs eligibility for certification; and

7. Gross negligence, incompetence, financial irresponsibility, or misconduct in the performance of contractual obligations or services.

ANY MATERIAL MISREPRESENTATION WILL BE GROUNDS FOR INITIATING ACTION

UNDER FEDERAL OR STATE LAWS CONCERNING FALSE STATEMENTS.

SIGNATURE: _________________________________DATE: __________________________

PRINT NAME: __________________________TITLE: ________________________________

On this _____day of ______________20___, before me appeared (name) __________________ to me personally known ____ OR produced___________________________________________ as identification, who being duly sworn, did execute the foregoing affidavit, and did state that he/she was properly authorized by (name of firm)______________________________________ to execute the affidavit and did so as a free act and deed.

(SEAL)

Notary Public: _____________________________________

My commission Expires: _____________________________

(Packet Rev. 5-14-2012)