Business Declaration_CSCS.doc
DOC document 74 KB Posted
- Solicitation number
- 6973GH-26-R-TBD
About this file
This is a Business Declaration form used by the Federal Aviation Administration to collect information about firm ownership and eligibility for set-aside contracts. The form requires contractors to provide basic company information including name, Tax Identification Number, DUNS Number, address, and contact details. Firms must identify the controlling interest holder and specify whether that individual is responsible for day-to-day management and policy decisions. The declaration includes checkboxes for various business classifications including minority-owned (Black American, Hispanic American, Native American, Asian American), women-owned, 8(a) certified, and Service Disabled Veteran Small Business designations.
The form also requests operational data such as North American Industry Classification code, nature of business, years in operation, number of employees, ownership type (sole proprietorship, partnership, or other), and gross receipts for the preceding three fiscal years. Firms must declare their status as small businesses, service-disabled veteran-owned small businesses, socially and economically disadvantaged small businesses, and women-owned small businesses. The declaration is subject to criminal penalties under 18 USCS 1001 for false statements. The FAA uses this information under its Acquisition Management System authority to determine business ownership and eligibility for set-aside contracting opportunities, with routine use permitted for sharing among small business development and contracting offices for statistical reporting purposes.
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Text version
BUSINESS DECLARATION
| 1 |
| Name of Firm: |
| Tax Identification No.: |
| 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) |
FORMCHECKBOX
a. Black American
FORMCHECKBOX
b. Hispanic American
FORMCHECKBOX
c. Native American
FORMCHECKBOX
d. Asian American
FORMCHECKBOX
e. Other Minority (Specify)
| FORMCHECKBOX |
f. Other (Specify)
FORMCHECKBOX
g. Female
FORMCHECKBOX
h. Male
FORMCHECKBOX
i. 8(a) Certified (Certification letter attached) FORMCHECKBOX
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? |
FORMCHECKBOX
a. Yes
FORMCHECKBOX
b. No (If “NO,” provide the name and telephone number of the person who has this authority.)
| 7 |
| Specify North American Industry Classification (NAIC) code |
| 8 |
| Nature of Business (Specify all services/products |
| 9 |
| (a) Years the firm has been in business |
| (b) No. of Employees |
| 10 |
| Type of Ownership: |
| FORMCHECKBOX |
a. Sole Ownership
FORMCHECKBOX
b. Partnership
FORMCHECKBOX
c. Other (Explain)
| 11. |
| 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 |
| 12. |
| Is the firm a small business? |
FORMCHECKBOX
a. Yes
FORMCHECKBOX
b. No
| 13. |
| Is the firm a service disabled veteran owned small business? FORMCHECKBOX |
a. Yes
FORMCHECKBOX
b. No
| 14. |
| Is the firm a socially and economically disadvantaged small business? FORMCHECKBOX |
a. Yes
FORMCHECKBOX
b. No
| 15 |
| Is the firm a woman-owned small business? FORMCHECKBOX |
a. Yes
FORMCHECKBOX
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.
| 16 a. Signature |
| b. Date: |
| c. Typed Name |
| d. Title: |
Privacy Act Statement: Privacy Act Statement (5 U.S.C. § 552a, as amended). AUTHORITY: FAA Acquisition Management System (49 USC 40110) authorizes us to collect this information. PURPOSE(S): We will use the information provided to determine your business ownership and eligibility for contracts set-aside for certain types of businesses. ROUTINE USE(S): We may share your information among our offices involved in small business development and contracting, and may also use the information for statistical reporting. DISCLOSURE: Providing the requested information is voluntary; however failure to furnish the information may result in ineligibility to participate in set-aside contracting.
Business Declaration (10/2013)
File details come from the government source that posted it. Updated .