Section 3 Package attachment.pdf

DCA Mandatory Section 3 Solicitation Package October 1, 2017 Page 5

Appendix B Section 3 Contract Non-Compliance Cure /Termination Processes

This language is a component of contract compliance with the work to which you are responding in this solicitation. The full requirements are provided in the Section 3 Clause found elsewhere in this package and in DCA’s Section 3 Policy for Covered HUD Funded Activities.

Any recipient, sub-recipient or contractor claiming Preference must be in compliance prior to issuance of a notice to proceed by DCA, recipient, sub-recipient, or contractor based on the policies established for the applicable DCA funding program. This preference can be met by any of the three qualifications:

1. Resident Owned Businesses (ROBs) owned and operated at 51% by Section 3 Residents.

2. Businesses that employ Section 3 residents at no less than 30% of the contractors aggregate full time staff.

3. Contractors that at the time of bid show evidence (meaning the specific name and preference met) of their intent to award no less than 25% of their total award to Section 3 business concerns.

The recipient, sub-recipient or contractor must maintain compliance throughout the life of the contract. The contractor understands and agrees that a compliance management firm may be used to conduct routine and certified payroll reviews to ensure compliance. The Contractor agrees to provide the payroll data in an Excel or Word format each time the payroll is processed throughout the contract.

Failure to meet the Section 3 requirements will result in penalties up to and including contract termination. Any contractor triggering the regulation by doing any hiring or contracting once they are awarded the contract through execution must comply with the Section 3 requirements by executing the efforts on their Certification and Action Plan in accordance with DCA’s Section 3 Policy.

DCA, the recipient, sub-recipient or contractor shall execute these remedies to achieve compliance in this order:

NON-COMPLIANCE CURE PROCESS

A. Based on the first observation or report of non-compliance with Section 3, the recipient, sub-recipient or contractor will be sent an e-mail by the compliance manager notifying them of their non-compliance issue. The recipient, sub-recipient or contractor will have until the next payroll or 10 business days, whichever is less, to bring the contract into compliance and/or justify in writing why they cannot meet compliance requirements.

B. DCA, the recipient, sub-recipient or contractor must render a response to the violating party within 10 business days of receipt of the violating party’s letter of reason for non-compliance. If DCA, the recipient, sub-recipient, or the contractor deems the reason to

DCA Mandatory Section 3 Solicitation Package October 1, 2017 Page 6 be unacceptable, at its option, DCA, the recipient, sub-recipient, or the contractor can extend the response period one time for up to 5 business days to allow the violating party to identify and secure other compliance options.

NON-COMPLIANCE TERMINATION PROCESS

If the violating party fails to take any corrective action to bring the contract into compliance within the allotted time, or DCA, the recipient, sub-recipient, or the contractor rejects any of the corrective plans and justifications for non-compliance, DCA, the recipient, sub-recipient, or the contractor will either terminate the contract immediately or impose liquidated damages equal to $100 a day for every day out of compliance. At DCA’s determination, any liquidated damages received must be paid to the recipient, sub-recipient or DCA, at DCA’s determination, and be used to promote economic opportunities for Section 3 Residents and Business Concerns.

DCA, the recipient, sub-recipient, or the contractor will hold all funds due to the violating party until such time that a financial workout is completed.

Additionally the violating party may be banned by DCA, the recipient, sub-recipient, and the contractor on future HUD funded projects.

DCA Mandatory Section 3 Solicitation Package October 1, 2017 Page 7

Appendix C Section 3 Forms

DCA Mandatory Section 3 Solicitation Package October 1, 2017 Page 8

Georgia Department of Community Affairs Required Submittal - Section 3 Self-Certification and Action Plan

All firms and individuals intending to do business with DCA, its recipients, sub-recipients and contractors MUST complete and submit this Action Plan and submit it with the bid, offer, or proposal in order to claim a preference on any contract or prior to award of a contract exceeding $100,000 if no preference is claimed. For contracts exceeding

$100,000, this document (signed, and notarized) must be satisfactorily completed to be eligible for award.

Business Name:

D.B.A. (if different from above):

Address: City: State/Zip:

Business Phone:

Fax:

E-Mail: Business Website:

Federal Employer Identification Number: Owner Social Security Number (if no EIN):

Contact Person & Title: Contact Phone:

Trade Description:

Carpentry Heating (HVAC) Electrical Painting

Masonry Restoration Asbestos Plumbing Roofing

Lead (Abatement) General Contractor Concrete Ironwork

Carpet/Flooring Rubbish Removal/Hauling Appraisal Services Landscaping

Demolition Other:

Date Business was established (MM/DD/YYYY): ________________________________

Type of Business (Check One): Corporation Partnership Sole Proprietorship

Limited Liability Corporation (LLC) Limited Liability Partnership (LLP) Joint Venture

Other (Describe):

Number of employees: Full-time: _______ Part-time: _______ Contract: _______ Total: _______

Section 3 employees: Full-time: _______ Part-time: _______ Contract: _______ Total: _______

DCA Mandatory Section 3 Solicitation Package October 1, 2017 Page 9

I am Certifying as a Section 3 Business Concern and requesting Preference accordingly (Select only One Option):

Option 1

A business claiming status as a Section 3 Resident-Owned Business Concern (ROB) entity:

_____Initial here to confirm selection of this option

Option 2

A business claiming Section 3 status, because at least 30% of the existing or newly hired workforce for this specific contract will be Section 3 residents throughout the entire contract period. If a Prime or

General Contractor is electing this option, the 30% employment requirement will be for the entire project including all the sub-contractors’ employees:

Check all methods you will employ to secure Section 3 Residents/Persons

Posting the position in community sources that are generally available to low income residents and the general public is a standard requirement. Check at least three (3) methods you will employ:

The local community newspaper The most widely distributed newspaper Company or agency website The management office of the local housing authority, or homeless service agency, or local low income housing community Local Workforce Board (i.e., Department of Labor) Local office of the Georgia Division of Family and Children Services Local office of the Georgia Department of Public Health Dodge Room http://www.construction.com/dodge/dodge.asp Other locations identified below and subject to DCA approval:

_____Initial here to confirm selection of this option

I anticipate my total number of employees for this contract to be ____ and _____ will be qualified Section 3 Residents/persons.

Option 3

A business claiming Section 3 status by subcontracting 25% of the dollar award to qualified Section 3

Business:

Attach a list of intended subcontract Section 3 business(es) with subcontract amount.

Attach certification & all supporting documentation for each planned subcontract Section 3 Business.

_____Initial here to confirm selection of this option

DCA Mandatory Section 3 Solicitation Package October 1, 2017 Page 10

I am NOT Requesting Preference under Section 3:

I am NOT certifying as a qualified Section 3 Business Concern and I am not requesting a preference.

However if I do trigger the regulation by doing any sub-contracting or hiring, I will comply by meeting all requirements of DCA’s Section 3 policy and am committing to do the outreach as specified below.

Check all methods you will employ to secure Section 3 Residents/Businesses

Posting the position/contract opportunity in community sources that are generally available to low income residents and Section 3 Businesses and the general public is a standard requirement. Check at least three

(3) methods you will employ:

The local community newspaper The most widely distributed newspaper Company or agency website The management office of the local housing authority, or homeless service agency, or local low income housing community Local Workforce Board (i.e., Department of Labor) Local office of the Georgia Division of Family and Children Services Local office of the Georgia Department of Public Health Dodge Room http://www.construction.com/dodge/dodge.asp Other locations identified below and subject to DCA approval:

_____Initial here to confirm selection of this option

Signature:

Printed/Typed Name:

Title:

Date:

Notarial Affidavit

Sworn to and subscribed before me this ___________ day of ____________________, 20_____.

Signature of Notary Public

Printed Name of Notary Public

Commission Expiration Date: ___________________________

(Notarial Seal)

DCA Mandatory Section 3 Solicitation Package October 1, 2017 Page 11

Georgia Department of Community Affairs Required Submittal - Previous Section 3 Compliance Certification

Name of Business:

Address of Business:

Type of Business (Check One): Corporation Partnership

Sole Proprietorship Other

Business Activity:

All firms and individuals intending to do business with DCA, its recpients, sub-recipients, or contractors

MUST complete and submit this certification of prior compliance prior to award of any contract exceeding

$100,000. Please check the appropriate line box below and sign and date the form.

1. I am certifying that I have complied with the HUD Section 3 Regulations, when triggered by new hiring or contracting opportunities, in my past contracts when required by the recipient, sub-recipient or contractor by either:

i. Certifying as Resident Owned Business (ROB); or,

ii. Employing Section 3 residents for at least 30% of the newly hired workforce; or,

iii. Subcontracting 25% of the total dollar award to a qualified Section 3 Business; or,

iv. Hiring or contracting to the “greatest extent feasible” with Section 3 Residents or Section

3 Businesses.

Check this box

2. I have never done any HUD funded contracting.

Check this box

3. I completed HUD Section 3 covered contracts in the past three years but the regulation was not triggered because either there were no new hires on the contract(s) and/or I did not do any new contracting or subcontracting.

Check this box

Signature:

Print Name:

Title:

DCA Mandatory Section 3 Solicitation Package October 1, 2017 Page 12

Required Submittal - Assurance of Compliance Certification Section 3 Action Plan

Housing and Urban Development Act of 1968 (12 U.S.C. 1701 U)

Contract/Solicitation Name or Number:

DCA Funding

Program:_______________________________________________________________

Entity Receiving DCA Funding Award:____________________________________

Purpose: To ensure that regulations promulgated under 24 CFR Part 135 Employment Opportunities for Businesses and Lower Income Persons in Connection with Assisted Projects and the Section 3 Policy of DCA, its recipients, sub-recipients and contractors to the greatest extent feasible is adhered to, and to serve as the “assurance of compliance” certification and action plan as required in the bid documents, supplemental general conditions, and required forms for the contract for any HUD work funded by DCA.

Description of the project’s work detail: The project work will be as listed in the final scope of work in the contract with DCA, its recipients, sub-recipients and contractors including any change orders.

List all known subcontractors below:

Subcontractor(s):

Subcontractor(s):

Subcontractor(s):

Subcontractor(s):

Subcontractor(s):

Subcontractor(s):

Subcontractor(s):

Subcontractor(s):

Use an additional sheet if required.

Note: If subcontractors are unknown at this time, print UNKNOWN on the line above. Also, the contractor must notify DCA or recipient or sub-recipient if subcontractors are added or changed during the contract. Any changes to this certification requires a resubmission of this form to DCA or recipient or sub-recipient.

DCA Mandatory Section 3 Solicitation Package October 1, 2017 Page 13

Preliminary Statement for Work Force Needs:

DCA intends to meet Section 3 compliance at the highest level and it is our intent to identify any short-term and long-term employment or contracting opportunities for qualified Section 3 persons and Business Concerns during the course of the contract funded by DCA via its recipients or sub-recipients and contractors. Please list the status of all planned employment positions and opportunities for this contract. Preference for all opportunities must be given to low and very low-income residents if they qualify. If awarded a contract, regardless of whether your firm has elected a preference, you are required to provide a list of your aggregate workforce on this project. Any changes to that workforce during the project will constitute NEW hires. You must notify DCA, its recipient, sub-recipient or contractor (respectively) overseeing your contract of any new hire opportunities that arise during the life of your contract. The anticipated workforce list may be provided on a separate sheet or in a different format.

List All Employees Date Hired

Section 3 Resident (Yes/No) Job Title/Trade

Salary Range

Name:

Address:

City, ZIP:

Name:

Address:

City, Zip Code:

Name:

Address:

City, Zip Code:

Name:

Address:

City, Zip Code:

Use additional pages as needed.

DCA Mandatory Section 3 Solicitation Package October 1, 2017 Page 14

“To the Greatest Extent Feasible”:

The Contractor has identified ___ # of OPEN positions with respect to this contract. The positions are filled by the _________________________________________ (Position title) of the Contractor.

Should the scope of work or duties of the contractor change to a degree requiring a modification of the work force needs, the contractor shall put forth a reasonable effort to fill vacant positions with eligible Section 3 residents.

Documentation of “To the Greatest Extent Feasible”:

The contractor will work with DCA, its recipients, sub-recipients, and contractors staff to notify residents of any opportunities afforded under the contract. The contractor will partner with DCA, its recipients, sub-recipients, and contractors by giving preference of any employment opportunities to the Section 3 persons or businesses.

The contractor shall recruit or attempt to recruit from the Section 3 area the necessary number of low-income and very low-income residents and Section 3 businesses, as applicable. The contractor must also document their recruiting efforts and any impediments to compliance with DCA’s Section 3 policy and the requirements of this solicitation package. This documentation must be submitted to the recipient or sub-recipient.

1. DCA, its sub-recipients and contractors shall: Maintain a list of all low-income area residents who have applied, either on their own or from referral from any source, and employ such person if otherwise eligible and if a trainee vacancy exists.

2. Conduct solicitation in accordance with DCA’s Section 3 policy and the requirements outlined in the solicitation package.

The contractor shall review all employment applications and determine if low-income and very low-income residents or Section 3 businesses meet minimum hiring or contracting qualifications. If these applicants meet such minimum qualifications, but are not hired due to lack of employment opportunities or for other reasons, they will be placed on a priority list and offered positions/contracts upon the occurrence of the first available appropriate opening.

Utilization of Section 3 Businesses Located Within the County:

The recipient, sub-recipient or contractor does ___ does not ___ intend to subcontract any of the work identified in the scope of work cited in the bid specifications, scope of work or General Conditions.

Should the scope of work or needs of the contractor change, the contractor shall, to the greatest extent feasible, assure that subcontracts be awarded to business concerns within the Section 3 covered area, or to business concerns owned in the substantial part (at least 51%) by persons residing in the Section 3 covered area.

Record Keeping:

The recipient, sub-recipient, contractor or subcontractor, as applicable, shall maintain on file all records related to employment and job training of low-income and very low-income residents or other such records, advertisements, legal notices, brochures, flyers, publications, assurances of compliance from sub-contractors, etc., in connection with this contract. If a report is needed in the future, the recipient, DCA Mandatory Section 3 Solicitation Package October 1, 2017 Page 15 sub-recipient, contractor or subcontractor, as applicable, agrees to provide all records upon request.

The contractor shall, upon request, provide such records or copies of records to HUD, DCA, their recipients, sub-recipients, contractors, staff, or agents. Records shall be maintained for at least three

(3) years after the close of the contract.

Reports:

The recipient, sub-recipient or contractor shall provide reports as required in connection with the contractor specifications. All certified and regular payrolls shall clearly detail which employees qualify under Section 3.

Certification:

The recipient, sub-recipient or contractor will certify that any vacant employment positions, including training positions that filled:

1) After the recipient, sub-recipient or contractor is selected but before the contract is executed, and

2) With persons other than those to who the regulations of 24 CFR Part 135 require employment opportunities to be directed, were not filled to circumvent the subcontractor’s obligations under 24 CFR Part 135.

Grievance and Compliance:

The recipient, sub-recipient, contractor or subcontractor hereby acknowledges that they understand that any low-income and very low-income resident of the project area, for him/her or as representatives of persons similarly situated, seeking employment or job training opportunities in the project area, or any eligible business concerns seeking contract opportunities may file a grievance if efforts to the greatest extent feasible were not executed. The grievance must be filed with HUD not later than one hundred eighty (180) calendar days from the date of the action (or omission) upon which the grievance is based.

I attest that the information on the preceding pages is true and correct.

Signature Date

Print Name

Title

DCA Mandatory Section 3 Solicitation Package October 1, 2017 Page 16

R E S I D E N T S E C T I O N 3 S E L F - C E R T I F I C A T I O N A N D S K I L L S D A T A F O R M

The purpose of this form is to comply with HUD Section 3 administration and certification regulations.

Certification for Section 3 Residents or other Low-Income Persons Seeking Employment, Training or Contracting

I, ________________________________________, am a legal resident of the United States and meet the income eligibility and federal guidelines for a Section 3 Resident as defined within this Certification.

My home address is: ____________________________________________________________________________ Must be a Street address not a P O Box # Apt Number

City State Zip Home # Cell #

County of Residence

Graduated High School or GED (month/year): I Read and Speak English Fluently: Yes or No

Attended College, Trade, or Technical School: Yes or No Graduated? Yes or No Year Graduated:__________

Check the Skills, Trades, and/or Professions in which you have been employed or contracted to do for others:

Drywall Hanging Drywall Finishing Interior Painting Framing HVAC Electrical Interior Plumbing Exterior Plumbing Siding Cabinet Hanging Door Replacement Trim/Carpentry Stucco Window/Door

Replacement Construction Cleaning Exterior Framing

Data Entry Receptionist Sales Telephone Customer Service

Administrative Teaching/Training Personal Care Aide Landscaping CDL License Roofing Concrete/Asphalt Work Heavy Equipment

Operator Fencing Metal/Steel Work Welding Other Other

I am certifying as a Section 3 Resident: Person seeking Training or Person seeking employment

(Check all that apply):

I am a public housing or section 8 Leaseholder I live in the service area

My total annual household income is $_____________. There are a total of _____ people living in my household.

I certify that all of the information given on this Certification is true and correct. If found to be inaccurate, I understand that I may be disqualified as an applicant and/or a certified Section 3 individual which may be grounds for termination of training, employment, or contracts that resulted from this certification. I attest under penalty of perjury that my total household income annually, based on my total household size as listed above is at or below the income amount for that specific size at the time of this document is being signed and notarized. I understand that proof of this statement may be requested in the future.

Signature Date

Printed Name: __________________________________

DCA Mandatory Section 3 Solicitation Package October 1, 2017 Page 17

Subrecipient or Contractor to Insert 2013 Income Limits for Project Location

Purpose:

The purpose of Section 3 of the Housing and Urban Development of 1968 (12 U.S.C. 1701u) (Section 3) is to ensure that employment and other economic and business opportunities generated by HUD Financial Assistance shall be directed to the Authority Residents and other low- and very low-income persons, particularly those who are recipients of government housing assistance and to business concerns which provide economic opportunities to Residents and other low- and very low-income persons.

Section 3 resident means:

(1) A public housing resident; or

(2) An individual who resides in the metropolitan area or non-metropolitan county in which the section 3 covered assistance is expended, and who is:

I. A low-income person, as this term is defined in section 3(b)(2) of the 1937 Act (42 U.S.C. 1437a(b)(2)). Section 3(b)(2) of the 1937 Act defines this term to mean families (including single persons) whose incomes do not exceed 80% of the median family income for the area, as determined by the Secretary, with adjustments for smaller and larger families, except that the Secretary may establish income ceilings higher or lower than 80% of the median for the area on the basis of the Secretary’s findings that such variations are necessary because of prevailing levels of construction costs or unusually high or low-income families; or

II. A very low-income person, as this term is defined in section 3(b)(2) of the 1937 Act (42 U.S.C. 1437a(b)(2). Section 3(b)(2) of the 1937 Act (42 U.S.C. 1437a(b)(2) defines this term to mean families (including single persons) whose incomes do not exceed 50% of the median family income for the area, as determined by the Secretary with adjustments made for smaller or larger families, except that the Secretary may establish income ceilings higher or lower than 50% of the median for the area on the basis of the Secretary’s findings that such variations are necessary because of unusually high or low family incomes.

(3) A person seeking the training and employment preference provided by section 3 bears the responsibility of providing evidence (if requested) that the person is eligible for the preference.

Service area means the geographical area in which the persons benefiting from the Section 3-covered project reside.

The figures below represent very low-income families; bottom figures represent low-income families. The most recent income limits established for each county may be found at:

http://www.hud.gov/offices/cpd/affordablehousing/programs/home/limits/income/.

FY 20XX

Income Limit

Area

Median Income

FY 20XX

Income Limit

Category

Person

Person

Person

Person

Person

Person

Person

Person

Very Low (50%) Income

Limits

Low (80%) Income Limits

DCA Mandatory Section 3 Solicitation Package October 1, 2017 Page 18

R E S I D E N T S E C T I O N 3 S E L F - C E R T I F I C A T I O N A N D S K I L L S D A T A F O R M

A F F A D A V I T

STATE OF ____________________

County of ______________________

I, ________________________________, a Notary Public of the City/County of _________________, State of __________________, do hereby certify that, _________________________________, whose name is signed to the writing above bearing date on the ____________ Day of __________________, 20_____, has acknowledged the same before me in my State aforesaid.

Given under my hand and official seal, this the ______ day of ___________________, 20___.

Signature of Notary Public

Printed Name of Notary Public

Commission Expiration Date: ___________________________

(Notarial Seal)

DCA Mandatory Section 3 Solicitation Package October 1, 2017 Page 19

SECTION 3 BUSINESS CONCERN SELF CERTIFICATION

The Georgia Department of Community Affairs (DCA) is seeking to extend the benefits of and to promote compliance with Section 3 by identifying Section 3 Business Concerns and targeting Section 3 Business Concerns for business opportunities, events and educational programs.

In an effort to comply with Federal Section 3 Regulations which promote contract, employment and training opportunities for State of Georgia residents, DCA has instituted a Section 3 Self Certification process.

Businesses seeking certification must complete and submit the attached Section 3 Business Concern Self Certification forms as follow:

1. If your company is qualified because it is owned (51% or more) by one or more Section 3 residents, then complete Form A, “Section 3 Business Concern – Resident Business Owner(s) Verification”;

OR

2. If your company is qualified because 30% or more of its full time permanent workforce are Section 3 Residents*, then complete Form B, “Section 3 Business Concern – 30% + Workforce”.

OR

3. If more than 25% of all subcontract work to be awarded shall be performed by Section 3 business concerns as described above, then complete Form C, “Section 3 Business Concern- Subcontractor”.

Please answer all questions, sign the completed forms, and notarize the affidavit.

Completed packets must be returned to the sub-recipient or contractor as follows:

Name of sub-recipient/contractor:

Attn:

Mailing Address:

If you have any questions or require assistance, please contact:

Name:

Phone Number:

Email Address:

DCA Mandatory Section 3 Solicitation Package October 1, 2017 Page 20

Form A

SECTION 3 BUSINESS CONCERN

Resident Business Owner(s) Verification

A business can be certified as a Section 3 Business Concern if the business is owned (51% or more) by Georgia Section 3 Resident(s).

Name of Owner: _______________________________________________________________

Home Street Address: _________________________________________________________

Home City, County, & Zip Code:

Name of Business: ______________________________________________________________

Percentage of Ownership: __________%

Low- to – Moderate Income (80% of Median) Check the appropriate box for your family size and income if your total household income is equal to or less than the Gross Household Income Maximum amount listed for your appropriate household size:

Check Box # of Persons in Household Gross Household Income Maximum

1 Individual

2 Individuals

3 Individuals

4 Individuals

5 Individuals

6 Individuals

7 Individuals

8 Individuals

(Effective ______________, 2013)

If the business is owned by more than one Section 3 resident, list each owner below and each should submit a separate Resident Business Owner Verification Form (Form A).

Please list additional Section 3 Resident owners of the business below:

Name Position % Percentage of Ownership

I certify that I am a resident of the State of Georgia and my total household income last year was not more than the amount shown above for my family size. I further certify the information provided is true and accurate and agree to provide upon request, documents verifying the information submitted to qualify as a Section 3 Business Concern.

Print: ________________________ Signature: _________________________ Date: _______________

DCA Mandatory Section 3 Solicitation Package October 1, 2017 Page 21

Form B

SECTION 3 BUSINESS CONCERN

30% + Workforce

A business can be certified as a Section 3 Business Concern if at least 30% of its permanent, full-time employees are Section 3 residents, or were Section 3 residents within three years of the date of the first employment with the business. You may also certify as a Section 3 Business Concern if, for this award, you will hire Section 3 residents for at least 30% of your permanent, full-time employees for this specific project. For your firm to be eligible UNDER THIS CRITERIA, you must provide the following information for all permanent, full-time employees.

You may attach additional copies of this chart, if necessary.

List All Employees Date Hired Section 3 Resident Job Title/Trade Salary Range

Name:

Address:

City/Zip:

Name:

Address:

City/Zip:

Name:

Address:

City/Zip:

Name:

Address:

City/Zip:

Name:

Address:

City/Zip:

Total Number of Employees: Full-Time:

Part-Time:

Contract:

Number of Section 3 Residents:

Section 3 % of Total Workforce:

I certify that the information provided is true and accurate and agree to provide upon request, any/all documents verifying the information submitted to qualify as a Section 3 Business Concern.

Print Name: ____________________________________________________________

Title: __________________________________________________________________

Company Name: ________________________________________________________

Signature: __________________________________________

Date: ________________________

DCA Mandatory Section 3 Solicitation Package October 1, 2017 Page 22

Form C

SECTION 3 BUSINESS CONCERN

Subcontractor Awarded

A business can be certified as a Section 3 Business Concern if the firm makes a commitment to subcontract in excess of twenty-five percent (25%) of the total amount of subcontracts to be awarded to: A) Section 3 Resident Owned Businesses; or B) Businesses for which 30% or more of their permanent full-time workforce is comprised of Section 3 Residents.

List all work performed by Section 3 Business Concerns Identified (This Form is to be updated as Section 3 Business Concerns are awarded through the completion of the project):

Name of Business Qualifying Conditions Total Contract Award

All identified Section 3 Business Concerns listed above are required to complete a Section 3 Self Certification Application (Forms A – C as appropriate) or provide proof of Section 3 Certification status.

Attach all required documents to this form.

I certify that the information provided is true and accurate and agree to provide upon request, any/all documents verifying the information submitted to qualify as a Section 3 business concern.

Print Name: ____________________________________________________________

Title: ___________________________________________________________________

Company Name: ______________________________________________________

Signature: __________________________________________

Date: ________________________