Business Self Certification Form.pdf

REQUEST FOR TAXPAYER IDENTIFICATION NUMBER

AND SIZE CERTIFICATION

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IN

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Legal Company or Individual Name: DBA Name:

Check appropriate box: □ Individual/Sole Proprietor □ Corporation □ Partnership □ Other

Address (number, street and apt. or suite no.)

City, State, and ZIP code

EIN or SSN - - DUNS Number

□ Woman-Owned Small Business

□ Veteran-Owned Small Business

□ Service-Disabled Veteran-Owned Small Business

□ Alaskan Native Corporation or Indian Tribe

NAICS Code - 6 digits NAICS Description Small Business (Y/N)?

Primary

Commodity: (check all that apply)

□ Advertising/Marketing Services □ Hospitality/Events/Food & Beverage □ Scientific/Research/Laboratory

□ Agriculture □ Human Resources & Personnel Services □ Shipping

□ Construction & Related Services □ IT □ Transportation/Automotive

□ Facilities/MRO □ Manufacturing □ Travel

□ Financial Services □ Medical

□ Furniture & Furnishings □ Printing/Publications/Promo

Certification: Under penalties of perjury, I certify that: (1) the number shown on this form is my correct taxpayer identification number, and (2) I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and (3) I am a U.S. person (including a U.S. resident alien).

NOTICE: Under 15 U.S.C. § 645(d), any person who misrepresents its size or socioeconomic status shall be (1) punished by a fine, imprisonment, or both; (2) subject to administrative remedies; and (3) ineligible for participation in programs conducted under the authority of the Small Business Act.

X Signature of Authorized Representative Date

Name (printed or typed) Title

Telephone Fax E-Mail Address

Business Size: (check one) □Small □Other Than Small Business (large, government, non-profit, foreign, individuals

Small Disadvantaged Business

Historically Black College or University

HUB Zone Small Business, S B A Certified

Minority Business Enterprise

Woman Business Enterprise smallbusiness@colostate.edu not identifying as a small business) may skip to Certification at the bottom

Small Business Classification:

INSTRUCTIONS

Please complete the top section of the certification form, providing as much information as possible, including your DUNS number. Dun & Bradstreet (D&B) provides a D-U-N-S Number, a unique nine-digit identification number, for each physical location of your business. D-U-N-S Number assignment is FREE for all businesses required to register with the US Federal government for contracts or grants.

Small Business Classification Definitions:

Small Business (SB) - A Small Business that is independently owned and operated by an American citizen and which is not dominant in its field of operation. The size definition will vary from industry to industry and is based on the North American Industry Classification System (NAICS) codes either by number of employees or gross annual sales. The website for Size Standard and NAICS lookup is:

https://eweb1.sba.gov/naics/dsp_naicssearch2.cfm

Small Disadvantaged Business (SDB) - An SB that is at least 51% owned and operated, or in the case of any publicly owned business, at least 51% of the stock of which is owned and operated by socially and economically disadvantaged individual or individuals. African Americans, Hispanic Americans, Asian Pacific Americans, Subcontinent Asian Americans, and Native Americans are presumed to qualify. Other individuals can qualify if they show a "preponderance of the evidence" that they are disadvantaged. All individuals must have a net worth of less than $750,000, excluding the equity of the business and primary residence. The website is: http://www.sba.gov/sdb/indexaboutsdb.html Must be certified as SDB by the Small Business Administration.

Women-owned Small Business - An SB that is at least 51% owned and operated by one or more women, or, in the case of any publicly owned business, at least 51% of the stock of which is owned by one or more women

Historically Underutilized Business Zone Small Business (HUBZone) - An SB with its principal office located within a HUBZone, which includes lands on federally recognized Indian reservations; owned and controlled by one or more U.S. citizens and at least 35% of its employees must reside in a HUBZone. The website is: https://eweb1.sba.gov/hubzone/internet/ Must be certified as HUBZone by the Small Business Administration.

Veteran-owned Small Business (VOSB) - An SB that is at least 51% owned and operated by one or more veteran(s), or, in the case of any publicly owned business, at least 51% of the stock of which is owned by one or more veterans, who actively served in the U.S. military, naval, or air service and were honorably discharged.

The website is: http://www.sba.gov/VETS/

Service-Disabled Veteran-owned Small Business - Same criteria as VOSB except the veteran has a disability that is service-connected.

NAICS Code: Provide your primary North American Industry Classification System (“NAICS”) codes, descriptions and size standard for the products or services that your company is providing. In addition, provide any other NAICS codes that you can be considered for doing business with Colorado State University. NAICS codes are needed for the Summary Subcontract Report breakout report that we are required to submit to the government annually pursuant to FAR 52.219-9(1)(2)(iii).

For legal definitions and assistance, contact your local Small Business Administration office. In Colorado, it is S B A, Colorado District Office, 721 19th Street, Suite 426, Denver, Colorado 80202, telephone 303-844-2607.

Size standard information is available at https://www.sba.gov/size-standards/ https://eweb1.sba.gov/naics/dsp_naicssearch2.cfm http://www.sba.gov/sdb/indexaboutsdb.html https://eweb1.sba.gov/hubzone/internet/