Business Declaration Form.pdf
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This document is a Business Declaration Form used by businesses to provide key company information for federal contracting purposes. The form captures comprehensive details about a company's ownership, demographics, business characteristics, and organizational structure, including:
Key elements include sections for identifying the firm's basic information (name, address, contact details), controlling interest (minority status, gender), ownership type, business nature, years in operation, employee count, and gross receipts. The form also requires declarations about business classification, such as small business status, service-disabled veteran ownership, and socially/economically disadvantaged business designation. The declaration includes a legal attestation that the provided information is true, with the signatory acknowledging potential criminal prosecution under 18 USCS 1001 for false statements.
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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 .