StdSelfCert.pdf

December 2011pw

MTC VENDOR SELF-CERTIFICATION FORM

Vendor/Company Name Contact Name

Mailing Address

_____________________________________ Phone # ___________________________

_____________________________________ Fax # ___________________________

_____________________________________ E-mail ___________________________

Project Name or Solicitation Number: ___________________________________

The North American Industry Classification System (NAICS) code (6-digit) for this company’s industry is:

(1)________________

(2)________________

(3)________________

(4)__________________

(5)__________________

(6)__________________

Section 1- Under FAR 52.219-8, all subcontractors must represent their business category per the attached “Definitions for Small Business Categories” per the stated project’s NAICS code.

Vendor Categories (check all that apply):

____ Small Business

____ Small Disadvantaged

____ Women-Owned

____ Veteran-Owned

____ Service-Disabled Veteran-Owned

____ HubZone

______ Large Business

______ Government

______ Non-Profit

Under Section 16 of the Small Business Act and Title 13 of the Code of Federal Regulations, any person or concern that knowingly misrepresents the small business size status of a person or concern in connection with federal government subcontracting opportunities is subject to penalties, including fines, imprisonment and debarment.

Section 2 - Under FAR 52.209-6, each proposed first-tier subcontractor, whose subcontract will exceed $30,000, must disclose whether as of the time of award of the subcontract, thee subcontractor, or its principals, is or is not debarred, suspended, or proposed for debarment by the Federal Government.

The Offerors and/or any of its Principals— Are are not presently debarred, suspended, proposed for debarment, or declared ineligible for the award of contracts by any Federal agency;

I certify that I have checked the appropriate categories for my company in Sections 1 & 2.

Signature of company representative Date

Printed Name Title

December2011pw

DEFINITIONS FOR SMALL BUSINESS CATEGORIES

For “MTC Vendor Self-Certification Form”

Small Business A small business as defined pursuant to Section 3 of the Small Business Act and relevant regulations.

(1) The Small Business Act states that a small business concern is “one that is independently owned and operated and which is not dominant in its field of operation.”

(2) The Act also states that the size standard varies from industry to industry. The Small Business Administration has established a table of size standards based on average annual receipts or average number of employees, which is matched to the North American Industry Classification System (NAICS). The table may be accessed at http://www.census.gov/eos/www/naics.

Small Disadvantaged Business (SDB) A small business concern that represents, as part of its offer that –

(1) It has received certification as a small disadvantaged business concern consistent with 13 CFR part 124, subpart B;

• 13 CFR 124.1001 (c) A firm may represent that it qualifies as an SDB for any Federal subcontracting program if it believes in good faith that it is owned and controlled by one or more socially and economically disadvantaged individuals.

• 13 CFR 124.1002 (c) Which is at least 51 percent unconditionally owned by one or more socially and economically disadvantaged individuals set forth in 124.105.

a) No material change in disadvantaged ownership and control has occurred since its certification;

b) Where the concern is owned by one or more individuals, the net worth of each individual upon whom the certification is based does not exceed $750,000 after taking into account the applicable exclusions set forth at 13 CFR 124.104(c)(2); and

c) It is identified, on the date of its representation, as a certified small disadvantaged business in the database Central Contractors Registration (www.ccr.gov ) Dynamic Small Business Search database maintained by the Small Business Administration, or

(2) It represents in writing that it qualifies as a SDB for any Federal subcontracting program, and believes in good faith that it is owned and controlled by one or more socially and economically disadvantaged individuals, and meets the SDB eligibility criteria of 13 CFR 124.1002.

Women-Owned Small Business A small business concern that

(1) Not less than 51 percent of which is owned by one or more women or, in the case of any public-owned business, not less than 51 percent of the stock of which is owned by one or more women, and

(2) The management and daily business operations of which are controlled by one or more women.

Veteran-Owned Small Business A small business concern that

(1) Not less than 51 percent of which is owned by one or more veterans (as defined in 38 USC 101(2)) or, in the case of any public-owned business, not less than 51 percent of the stock of which is owned by one or more veterans, and

(2) The management and daily business operations of which are controlled by one or more veterans.

Service-Disabled Veteran-Owned Small Business A small business concern that –

(1) Not less than 51 percent of which is owned by one or more service-disabled veterans or, in the case of any public-owned business, not less than 51 percent of the stock of which is owned by one or more service-disabled veterans

a. The management and daily business operations of which are controlled by one or more service-disabled veterans or, in the case of a service-disabled veteran with permanent and severe disability, the spouse or permanent caregiver of such veteran.

(2) “Service-disabled veteran” means a veteran, as defined in 38 USC 101(2), with a disability that is service-connected, as defined in 38 USC 101(16).

HUBZone Small Business A small business concern must appear on the List of Qualified HUBZone Small Business Concerns maintained by the Small Business Administration. (More information about the HUBZone Small Business program and its benefits to qualifying companies can be obtained from the Small Business Administration.)

http://www.census.gov/eos/www/naics� http://www.ccr.gov/�