ATTACHMENT_03_SMALL_BUSINESS_PARTICIPATION_FORM_FINAL.docx

ATTACHMENT 3 – Small Business Participation Form Small Business Participation Form – Attachment 3 Modernizing Instrumentation Solutions for Test and Evaluation

(MISTE)

1. CONTRACT NUMBER: ______________________

2. SOCIOECONOMIC STATUS: SDB ___ WOSB ___ HUBZone ___ VOSB ___

SDVOSB ___ LB ___

3. THE GOALS OF SMALL BUSINESS PARTICIPATION PER CONTRACT IS AS FOLLOWS: SB (20%) of all awarded Delivery Orders on a cumulative basis.

4. Subcontract Awards

e. Comments:

Small Business Participation Form – Attachment 1 Modernizing Instrumentation Solutions for Test and Evaluation

(MISTE)

Page 2 - INSTRUCTIONS GENERAL INSTRUCTION: The intent of this form is to collect subcontract award data from prime contractor(s). The report should reflect the cumulative total from inception of the contract award. This data will be measured against the goals set forth in block 4. The report shall be submitted to Joseph Candelaria, Contract Specialist, utilizing one of the following methods:

E-mail: joseph.candelaria5.civ@mail.mil. (Preferred Method) Mail: U.S. Army Contracting Command (ACC) -Orlando ATTN: Joseph Candelaria CCCOR-CDD-B 12211 Science Drive Orlando, FL 32826-3224

SPECIFIC INSTRUCTIONS:

Block 1. Enter the Contract number.

Block 2. Indicate your Socio-Economic status by checking the appropriate block/blocks.

Block 4. Indicate cumulative dollar funded and percentage subcontracted for each category. Follow these two steps to complete this block:

STEP 1. Complete the spreadsheet on page 3. This spreadsheet provides supportive data that identifies each subcontractor under the applicable socio-economic status.

STEP 2. Forward the totals of each category to the appropriate blocks on page 1. Block 4a. Report all subcontracts awarded to Small Business (SB) to include subcontracts to SDBs, WOSBs, VOSBs, HUBZone SBs, SDVOSB, and HBCU/MSIs.

Block 4a (1). Report all subcontracts awarded to Small Disadvantaged Businesses (SDB).

Block 4a (2). Report all subcontracts awarded to Women-Owned Small Businesses (WOSB).

Block 4a (3). Report all subcontracts awarded to HUBZones Small Businesses (HUBZone SB).

Block 4a (4). Report all subcontracts awarded to Veteran-Owned Small Business (VOSB).

Block 4a (5). Report all subcontracts awarded to Service-Disabled Veteran-Owned Small Business (SDVOSB).

Block 4b. Report all subcontracts with Historically Black Colleges/Universities and Minority Serving Institutions (HBCU/MSI).

Block 4c. Report all subcontracts awarded to Large Businesses (LB).

Block 4d. Report the total subcontract effort by adding Block a, b and c.

Block 4e. If you did not meet the goal identified in block 3 of the form, please indicate in the comment section the reason why the goal were not met and the plan to meet the goals in the future.

Small Business Participation Form – Attachment 1 Modernizing Instrumentation Solutions for Test and Evaluation

(MISTE)

Page 3 - SPREADSHEET INSTRUCTIONS: List each subcontractor under the appropriate socioeconomic category. A subcontractor can be listed under more than one category, if applicable. Also, the subcontractors listed in block (a) should reflect the subcontractors listed in blocks (1) through (4). For example, if subcontractors X, Y, and Z were listed in block (a), subcontractor X could be a SDB, subcontractor Y a WOSB and subcontractor Z just a SB. Total each category and bring the total Dollar Funded and % forward to the associated blocks on page 1.

a. SMALL BUSINESS CONCERNS (include SDB, WOSB, HUBZone SB, SDVOSB, and VOSB

1. SMALL DISADVANTAGED BUSINESS (SDB)

2. WOMAN OWNED SMALL BUSINESS (WOSB)

3. HUBZone SMALL BUSINESS (HUBZone)

4. VETERAN-OWNED SMALL BUSINESS (VOSB)

5. SERVICE DISABLED VETERAN OWNED SMALL BUSINESS (SDVOSB)

6. HISTORICALLY BLACK COLLEGES & UNIVERSITIES & MINORITY SERVICING INSTITUTIONS (HBCU/MSI)

Comments/Explanations:

Submitted and Certified by (Company Representative):

Date:

SOURCE SELECTION INFORMATION (SEE FAR 3.104)