DRAFT Attachment 0179 - Small Business Participation Cert.pdf

Form version: 27 Mar 2019

Certification Form Small Business Size and Socioeconomic Status

For Proposed Subcontractors Not Registered in the System for Award Management (SAM) Instructions for Prime Offeror:

1. Obtain this certification from any small business listed in the proposal that is not registered in SAM at https://www.sam.gov.

2. Before sending to a subcontractor to fill in, insert the Solicitation Number, NAICS code associated with the work to be done by the subcontractor, and the size standard for that NAICS code. Insertion of subcontract number or other internal tracking code is optional.

Instructions for Subcontractor:

1. Do not fill in this form if the NAICS code or one of the size standard fields has not been filled in by the prime offeror.

2. Fill in the other fields below. {The fields will expand as you type.}

3. Provide Name, Title, and Signature of official authorized to sign for the company and the date.

Solicitation Number: W56HZV-{ }-{ }-{ }

Subcontract Number or Other Internal Tracking Code (Optional): { }

Company Name: { }

Address: { }

I hereby certify that for the North American Industry Classification System (NAICS) code of { } defined in https://www.census.gov/eos/www/naics/ with a size standard of { } employees / $ { } average annual receipts assigned at https://www.sba.gov/contracting/getting-started-contractor/make-sure-you-meet-sba-size-standards, the above named business is a (check all that apply):

Small Business (SB) Small Disadvantaged Business (SDB) Woman Owned Small Business (WOSB) Veteran Owned Small Business (VOSB) Service Disabled Veteran Owned Small Business (SDVOSB) as defined in Federal Acquisition Regulation (FAR) 2.101, FAR Clause 52.219-8, and taking into consideration the 13 CFR 121.103 “How does SBA determine affiliation” at http://www.ecfr.gov.

The contractor may self-certify in the above categories. A Contractor cannot self-certify as an 8(a) Small Disadvantaged Business or a Historically Underutilized Small Business Zone Small Business (HUBZone SB). These require certification by the Small Business Administration (SBA) and registration in the System for Award Management (SAM) and the SBA’s Dynamic Small Business Search Database.

Official authorized to sign for the company

Name: { }

Title: { }

Electronic Signature: { } or Handwritten Signature: _______________________________________________________________

Electronic Date: { } or Handwritten Date: ___________________

DRAFT

Attachment 0198 https://www.sam.gov/ https://www.census.gov/eos/www/naics/ https://www.sba.gov/contracting/getting-started-contractor/make-sure-you-meet-sba-size-standards http://www.ecfr.gov/