Instructions - Form 404: Annual Certification - Qualified Nonprofit Agency Serving People Who Are Severely Disabled

INSTRUCTIONS FOR ANNUAL CERTIFICATION

FORM 404

1. NAME OF AGENCY - Use the incorporated name of the agency as stated in your Articles of Incorporation.

2. ADDRESS - The address should normally be the address where the executive director/president is located.

3. PHONE - Self explanatory.

4. FISCAL YEAR ENDING - Self explanatory.

5A Direct labor means all work required for preparation, processing, and packaging of a commodity or work directly related to the performance of a service, but not supervision, administration, inspection or shipping. Work performed by a subcontractor as a regular part of providing the commodity or service would not be included; (However, a subcontract to provide temporary workers would be included as direct labor hours). Include hours for vacation, holiday and sick leave.

5B. through 5D. Self explanatory.

5E. If during the last twelve months the agency has revised any of the documents used by the Committee to make the verification of nonprofit status, a copy of the revised documents must be sent to the Committee. For private nonprofit agencies this would include the Articles of Incorporation and Bylaws; for State operated agencies this would include State Statutes and Implementing Regulations. Check the block to indicate whether or not changes have been made and if so, fill in the appropriate information.

5F. Self explanatory.

5G. Self explanatory.

6A. Enter the total direct labor hours paid to people with severe disabilities for the fiscal year,

October 1 of last year through September 30 of this year.

6B. Enter the total direct labor hours paid to people without severe disabilities for the fiscal year.

6C. This is the sum of items 6A and 6B. It should be the total of all direct labor work performed

by the agency in the fiscal year.

6D. Under blind indicate the number of people who have been employed by the agency in the last

fiscal year who have blindness as a disability. Under total indicate the number of people, including those who are blind, who have been employed by the agency in the last fiscal year.

7A. Enter the direct labor hours paid to all AbilityOne employees who with severe disabilities for the fiscal year, October 1 of last year through September 30 of this year. Under products, list the hours for all AbilityOne products; under services, list the hours for all AbilityOne services.

7B. Enter the direct labor hours paid to all AbilityOne employees who are sighted for the fiscal year, breaking them out for AbilityOne products and services.

7C. This is the sum of items 7A and 7B. It should be the total of all AbilityOne direct labor work

performed by the agency during the fiscal year.

7D. This is the percentage of direct labor hours paid to people with severe disabilities on AbilityOne product and service contracts. Figure this percentage by dividing the amount in line 7A by the amount in line 7C.

7E. Indicate the number of people who have blindness as a disability that have worked on AbilityOne products during the last year; the number of people who have blindness as a disability that have worked on AbilityOne services; and the total under the appropriate columns.

7F. Indicate the total number of people, including those who are blind, that have worked on

AbilityOne Products during the last year; Indicate the total number of people, including those who are blind, that have worked on AbilityOne Services during the last year; and the total under the appropriate columns.

7G. Indicate the total amount of wages paid to AbilityOne employees with severe disabilities. This total should include vacation, holiday, sick leave pay, and cash health and welfare payments required by the Service Contract Act.

8A. Indicate the number of people with severe disabilities that have been placed into competitive

employment during the last fiscal year. The number is to be broken down to indicate placement from AbilityOne projects, non AbilityOne projects, and direct placements as well as the agency total. Placement of an individual onto an AbilityOne job can only be counted if the individual's hours are not counted towards the 75% direct labor ratio requirement. It is important to note the definition of competitive employment used by the Committee: that the individual is capable of obtaining and maintaining the job without assistance. This means that supported employment positions are not considered competitive employment. Direct placement means that the agency placed an individual into a competitive job, but the individual never performed direct labor at the agency.

8B. Indicate the number of people with severe disabilities that have been placed into supported

employment during the last fiscal year. The number is to be broken down to indicate placement from AbilityOne projects and non AbilityOne projects and direct placements as well as the agency total. These placements would be all workers who had been placed into positions other than competitive employment. Placement of an individual onto an AbilityOne job does not count towards this total. Direct placement means that the agency placed an individual into a supported job, but the individual never performed direct labor at the agency.

8C. This question seeks information on people with severe disabilities who are working for the

agency, not in supervisory or management positions, (whether a in a client or other employee status) and who were promoted to a new job or workstation within the agency that paid increased wages or benefits. This question should not include individuals whose wage increased due to cost of living raises or productivity increases. Do not include people who continued to perform the same job but were hired from a client status into a permanent employee status.

8D. This question seeks information on people with severe disabilities are who are working for the

agency (whether a client or other employee status) and who were promoted to a new job or workstation within the agency that paid increased wages or benefits and which included increased supervisory, management or technical skills. This question should not include individuals whose wage increased due to cost of living raises or productivity increases. Do not include people who continued to perform the same job but were hired from a client status into a permanent employee status.

9A. AbilityOne sales are broken into three categories: Military Resale, Products and Services. Reportonly the value of those Military Resale items that were produced in the agency. Services are items that were added to the Procurement List as services and products are items that were added to the Procurement List as products. Report on each line the sales from the previous fiscal year. Line 4 is the total AbilityOne sales and will equal the sum of lines 1 through 3.

9B. Indicate sales by Base Supply Centers to Federal customers. Those agencies that sell directly

to Base Supply Centers should continue to record those sales as AbilityOne sales.

9C. Indicate the total of any Federal sales not recorded as AbilityOne sales or Base Supply Center

sales.

9D. Indicate the total of all other agency sales and subcontracting work.

9E. Total agency sales is the sum of 9A, 9B and 9C.

10. In this section, show all forms of cash and noncash compensation received by each listed key

employee, whether paid currently or deferred, during the fiscal year covered by this annual certification. Include compensation received from any and all affiliated or related entities. If you pay any other person, such as a management services company, for the services provided by any of your key employees, report the compensation as if it had been paid directly to your key employees. All fields must provide the appropriate dollar amount; entering a phrase such as “Information available upon request” is unacceptable.

10A. List each person who was a key employee (defined below) at any time during the fiscal year

covered by this annual certification. Provide a contact address for each person listed. A “key employee” is any person having responsibilities or powers similar to those of officers, directors, or trustees. The term includes the chief management and administrative officials of an organization (such as a CEO, President, Executive Director, or equivalent) but does not include the heads of separate departments or smaller units within an organization. A chief financial officer and the officer in charge of administration or program operations are both key employees if they have the authority to control the organization’s activities, its finances, or both. The “heads of separate departments” are managers within their specific areas but not for the organization as a whole and, therefore, are not key employees.

10B. For each person listed, provide the position title and a numerical estimate of the average hours per week devoted to the position. Statements such as “as needed,” “as required,” or “40+” are unacceptable.

10C. For each person listed, report salary, fees, bonuses, and severance payments paid during the

fiscal year covered by this annual certification. Include payments of amounts reported or reportable as deferred compensation in any prior year.

10D. For each person listed, provide all forms of deferred compensation and future severance

payments (whether funded or not; whether vested or not; and whether or not the deferred compensation plan is a qualified plan under section 401(a)) paid during the fiscal year

covered by this annual certification. Include also payments to welfare benefit plans on behalf of the key employee. Such plans provide benefits such as medical, dental, life insurance, severance pay, disability, etc. Reasonable estimates may be used if precise cost figures are not available. Unless the amounts were reported in column 10(C), report, as deferred compensation in this column, salaries and other compensation earned during the fiscal year covered but not yet paid by the date this annual certification was filed with the central nonprofit agency.

10E. For each person listed, enter taxable and nontaxable fringe benefits provided during the fiscal

year covered by this annual certification. Include amounts recipients must report as income on their separate income tax returns. Examples include amounts for which the recipient did not account to the agency or allowances that were more than the payee spent on serving the agency. Include payments made under indemnification arrangements, the value of the personal use of housing, automobiles, or other assets owned or leased by the agency (or provided for the agency’s use without charge), as well as any other taxable and nontaxable fringe benefits.

Paperwork Burden Statement:

The information collected by this form is mandatory and required in order for the nonprofit agency to obtain or retain the benefits of participation in the AbilityOne Program (41 U.S.C. 46-48c, 41 CFR 51). This information is used to ensure that nonprofit agencies participating in the AbilityOne Program are meeting the Program’s requirements. The estimated burden per respondent is 3 hours and the cost of sending the form to NISH. The OMB control number is 3037-0002, which expires on xx-xx-xxxx. A Federal agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Comments on this information collection may be submitted to the Information Collection Clearance Officer, Committee for Purchase From People Who Are Blind or Severely Disabled, Jefferson Plaza 2, Suite 10800, 1421 Jefferson Davis Highway, Arlington, VA 22202-3259.