Business Declaration Form..pdf
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- Instrument Landing System Draft Specification
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About this file
This document is the FAA Business Declaration form (OMB Control No. 2120-0595, FAA Template No. 61, rev. 10/08), a template used to collect business information from firms seeking federal contract opportunities with the Federal Aviation Administration.
The form requires firms to provide core identification data including company name, tax identification number, DUNS number, address, and contact information for the person making the declaration. Section 5 captures ownership characteristics for small business set-asides and socially and economically disadvantaged business classifications, including options for Black American, Hispanic American, Native American, Asian American, female, male, 8(a) certified, and service disabled veteran-owned business designations. Additional business information collected includes nature of business by NAIC code, years in operation, number of employees, type of ownership structure (sole ownership, partnership, or other), and gross receipts for the three preceding years. The form includes yes/no questions regarding small business status, service disabled veteran-owned small business status, and socially and economically disadvantaged small business status. The declaration requires the signatory to attest under penalty of criminal prosecution under 18 USCS 1001 that all statements are true and correct to the best of their knowledge, information, and belief. The signatory must provide their signature, date, typed name, and title.
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Text version
OMB Control No. 2120-0595 FAA Template No. 61 (rev. 10/08)
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)
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 .