506-09b_vendor_questionnaire 1 .doc

VENDOR QUESTIONNAIRE

FROM:

Gadsden Job Corps Center

Date: _________________

Adams and Associates, Inc.

600 Valley Street

Gadsden, AL 35901

Email Address: - sesay.kelly@jobcorps.org

ATTN:

To whom it may concern:

Completion of this form and W-9 is required in order for your business to receive full payment for goods and services. If you are a small business, please read the attached small business certification and check the appropriate designation(s) below.

Type of Service Provided _______________________________________________________ Company Name _______________________________________________________________ (Legal entity or IRS filing name for tax purposes – should match Line 1 of W-9 Form) DBA (if applicable):____________________________________________________________ For applicable 1099 issuing purposes, please provide how your business files with the IRS:

Corporation Individual Other _________________________________________ DUNS Number: ________________________ (Required) Street Address: ___________________________________________________________________________________ (Physical address) City:

_____________________________ State & (nine digits) Zip Code: _____________________ Remittance Address (if different): _______________________________________________ City:

__________________________ State & Zip: __________ Congressional District: ______________________ Telephone #: _________________________ Fax #: _________________________

Check all Categories that Apply:

1. Small Business

2. Small Disadvantaged Business (8a must be SBA Certified)*

3. Women Owned Small Business

4. HUB Zone Small Business (Must be SBA Certified)*

5. Veteran Owned Small Business

6. Service-Disabled Veteran Owned Small Business

7. Historically Black College/University or Minority Institution

8. Large Business

9. Government

10. Non-Profit *Primary NAICS Code (for SBA Certified business): _________________________ Description of the products or services provided - __________________________________________________________________________________________

Executive Pay Reporting Executive pay of the five most highly paid executives of the subcontractor if the subcontractor meets all of the following conditions (Please see FAR 54-204-10):

Check each of the statements and questions below that are true or to which the answer is yes:

Does your company receive 80 percent or more of annual gross revenues from Federal contracts, subcontracts, loans, grants (and sub-grants) and cooperative agreements and

Does your company receive $25,000,000 or more in annual gross revenues from Federal contracts, subcontracts, loans, grants, (and sub-grants) and cooperative agreements and

The public does not have access to information about the compensation of the executives through periodic reports filed under section 13(a) or 15(d) of the Securities Exchange Act of 1934 (15 U.S.C. 78m(a), 78o(d)) or section 6104 of the Internal Revenue Code of 1986

Signature and Title of Individual Completing Form

Date

Print Name & Title

SMALL AND SMALL DISADVANTAGED BUSINESS CERTIFICATION

Adams and Associates, Inc. participate in the Government’s Small and Small Disadvantaged Business programs. This requires written certification from our suppliers and contractors as to their business status. Please furnish the information requested below.

1.0 Small Business – An enterprise independently owned and operated, not dominant in its field and meets employment and/or sales standards developed by the Small Business Administration. [See 13 CFR 121] 1.a Small Disadvantaged Business – a Small Business Concern owned and controlled by socially and economically disadvantaged individuals; and [See 13 CFR 124.125]

(1) Which is at least 51% owned by one or more socially and economically disadvantaged individuals; or in the case of any publicly owned business, at least 51% of the stock of which is owned by one or more socially and economically disadvantaged individuals and

(2) Whose management of daily operations do one or more such individuals control? The contractor shall presume Black Americans, Hispanic Americans, Native Americans (such as American Indians, Eskimos, Aleuts and Native Hawaiians), Asian-Pacific Americans and other minorities or any other individual found to be disadvantaged by the Administration pursuant to Section 8 (a) of the Small Business Act and

(3) If the Vendor is an 8(a) business, it must be certified by the SBA as a Small Disadvantaged Business. If not an 8(a) business, the Vendor may self-certify as a Small Disadvantaged Business if the above criteria are met.

1.b Women-Owned Business Concern – A business that is at least 51% owned by a woman or women who are United States citizens who also control and operate it. Control in this context means exercising the power to make policy decisions. Operate in this context means being actively involved in the day-to-day management.

1.c HUB Zone Small Business Concern – A business that must appear on the List of Qualified HUB Zone Small Business Concerns maintained by the Small Business Administration. [See 13 CFR 126.103].

1. d Veteran-Owned Small Business Concern – A business that is at least 51% owned by one or more veterans; or in the case of any publicly owned business, at least 51 % of the stock of which is owned and controlled by one or more veterans and the management and daily business operations of which are controlled by one or more veterans.

1. e Service Disabled Veteran-Owned Small Business - A business that is at least 51% owned by one or more service disabled veterans; or in the case of any publicly owned business, at least 51 % of the stock of which is owned and controlled by one or more service disabled veterans and the management and daily business operations of which are controlled by one or more service disabled veterans. Service disabled veteran means a veteran as defined in 38 U.S.C. 101(2) with a disability that is service connected as defined in 13 U.S.C 101(16).

Notice: In accordance with 15 U.S.C. 645(d)., any person who misrepresents a firm’s proper size classification shall (1) be punished by imposition of a fine, imprisonment, or both; (2) be subject to administrative remedies; and (3) be ineligible for participation in programs conducted under the authority of the Small Business Act.

If you have difficulty determining your size status, you may contact the Small Business Administration at 1-800-U-ASK-SBA OR 202-205-6618. You may also access the SBA website at www.sba.gov/size or you may contact the SBA Government Contracting Office at answerdesk@sba.gov or 817-827-5722. (Rev.10/2011)

NOTE:

This certification is valid unless you notify us of any changes. It is your responsibility to notify us if your size or ownership status changes. Vendor Questionnaires and vendor lists are subject to change and are not used for any other purpose than general market research and to support contracting plan initiatives to locate small businesses.

Form FA506.09b Rev 11/12