Form SBA 1010-AIT, -ANC SBA 1010-AIT, -ANC 1010B Applications

OMB Approval No. 3245-0331

Expiration Date:

APPLICATION FOR ADMISSION TO THE 8(A) BUSINESS DEVELOPMENT (BD) PROGRAM

OR CERTIFICATION AS A SMALL DISADVANTAGED BUSINESS (SDB)

YOUR SIGNATURE ON THIS FORM INDICATES THAT YOU FULLY UNDERSTAND ALL QUESTIONS AND CERTIFIES THAT ALL RESPONSES AND DOCUMENTS ARE TRUTHFUL AND ACCURATE.

Name of Applicant Business Concern (include any trade or d.b.a. names): ________________________________

Business Concern is Applying For (check one):

8(a) [ ] New SDB Business concern Only [ ] Recertified SDB Business concern Only* [ ]

(All 8(a) certified business concerns are automatically certified as SDBs)

* If the applicant business concern’s SDB certification has been expired for more than 90 days, the business concern must check “new SDB Business Concern Only” and submit all documents required for new SDB certification applicants.

INFORMATION ABOUT THE 8(a) AND SDB APPLICATION

This Form is to be completed by all 8a and SDB applicants.

Limitation on 8(a) BD Eligibility: A business concern can participate in the 8(a) BD Program only one time. Similarly, a socially and economically disadvantaged individual can use his or her disadvantaged status to qualify for the program only one time.

Authority to Collect Information: The U.S. Small Business Administration (SBA) is authorized to determine eligibility for the 8(a) Business Development (BD) Program under 13 C.F.R. Part 124, Subpart A and for Small Disadvantaged Business (SDB) certification under 13 C.F.R. Part 124, Subpart B. The information submitted on this SBA Form 1010 is used to determine the applicant’s eligibility for one or both of these programs.

Disclosure of Information: SBA will keep the application and supporting documentation provided with the application confidential to the extent required by law. However, all information submitted in connection with this application may be disclosed to Federal procurement agencies considering furnishing contracts to the applicant firm or to Federal, State and local agencies for law enforcement purposes. Any sensitive information collected in this application is necessary to determine if applicants meet statutory and regulatory requirements. Any sensitive information collected is maintained in compliance with the Privacy Act.

RESOURCES AND DEFINITIONS FOR SUBMITTING YOUR APPLICATION

• Online application information, answers to frequently asked questions, and the address to send the application and forms identified in this application can be found at the 8(a) BD Program and SDB websites: http://www.sba.gov/aboutsba/sbaprograms/8abd/index.html. Please note that the information is updated periodically.

• Regulations for the 8(a) and SDB Programs (Title 13 C.F.R. Part 124) are available at: http://www.sba.gov/tools/resourcelibrary/lawsandregulations/index.html

Affiliate or Affiliation may be present when there is common management, ownership, or control between the applicant business concern and another business concern or when there are contractual relationships, prior relationships, familial ties, common investments or economic dependence on another business concern. For more information on affiliation, see 13 C.F.R. § 121.103.

AIT means an American Indian Tribe. All applicant business concerns owned by an AIT must complete this form and have the AIT complete the Form 1010-AIT.

ANC means an Alaska Native Corporation. All applicant business concerns owned by an ANC must complete this form and have the ANC complete the Form 1010-ANC.

CDC means a Community Development Corporation. All applicant business concerns owned by a CDC must complete this form and have the CDC complete the Form 1010-CDC.

CCR is the Central Contractor Registration primary registrant database for the U.S. Federal Government, maintained by the U.S. Department of Defense. You must register or update your business concern’s profile at http://www.ccr.gov/ prior to submitting your application.

DSBS is the U.S. Small Business Administration’s Dynamic Small Business Search database. You must register in this database as part of the registration in the CCR. The DSBS will generate a user number which is the SBA identification number.

Immediate Family Member means father, mother, husband, wife, son, daughter, brother, sister, grandfather, grandmother, grandson, granddaughter, father-in-law, and mother-in-law.

Key Employee is an employee who, because of his/her position in the concern, has critical influence in or substantive control over the operations or management of the concern.

NAICS is the North American Industry Classification System. You may learn more about NAICS by accessing the Census Bureau’s NAICS Internet site at: http://www.census.gov/epcd/www/naics.html.

NHO means a Native Hawaiian Organization. All applicant business concerns owned by an NHO must complete this form and have the NHO complete the Form 1010-NHO.

Primary NAICS represents the business concern’s largest source of revenues for the most recently completed fiscal year. More information about NAICS and size standards is available at the Small Business Size Standards website http://www.sba.gov/services/contractingopportunities/sizestandardstopics/index.html.

Principal is an owner of 10% or more or a director, management member, partner, officer or key employee.

Size means that in order to be eligible for the 8(a) BD program or SDB certification, an applicant business concern must be a small business concern. 13 C.F.R. § 124.102. SBA will determine size based on the applicant business concern’s primary NAICS code either based on three years of average revenues, or the number of employees as recorded on business tax returns and payroll records. 13 C.F.R. § 121.201 lists NAICS codes and their respective size factor (either revenue or number of employees). If the applicant business concern has any affiliates (see definition above), the revenue/employees of those affiliates will be included in this calculation except the revenue/employees of an AIT, ANC, CDC, or NHO, or a company owned by one of these entities, will not be counted.

OTHER APPLICATION INFORMATION

Incomplete Applications: All complete applications will be processed; incomplete applications will be returned.

If the application is not complete, SBA will return the application to you along with a list of missing or incomplete documentation. You may then reapply when the application is complete.

Use of Representatives: If a third party that is not employed by the applicant business concern completed or helped to complete this application, complete Form 1010-REP and submit it with your application materials.

SECTION I

Business Profile

Telephone: ( )____________________ Fax: ( )_________________________

Address: _______________________________________________________________________

City: _____________________ County: _____________ State: ______________ Zip: ______________

E-mail: __________________________________________ @ ____________________________

Business concern’s Primary Point of Contact: _______________________________________

Mailing Address (if different from above)

Address: _____________________________________________________________________

City: _____________________ State: ______________ Zip: ______________

Type of Business:

 Manufacturing  Retail Dealer  Non-Professional service

 Construction  Professional Service  Wholesaler

 Concession  Franchise  A Broker

Primary NAICS Code: ___________________________________________________________

(North American Industry Classification System)

Dynamic Small Business Search#: __________________________________________________

Mandatory for 8(a) & SDB Certification

Company Employer Identification Number (EIN)_____________________________________________

Date business concern established: _____________________________

Dun & Bradstreet Number: __________________________________________________

Mandatory for 8(a) & SDB Certification

This business concern is (check all applicable):

 A For-Profit Business  A Non-Profit Business

 A Proprietorship  A Corporation

 A Partnership  A Limited Liability Company

What is the average number of employees the business concern (with its affiliates, as defined on page 1) had during the past 12 months? ________________________.

What percentage of the business concern’s revenues was earned in the primary NAICS Code during the past twelve months? ___________________ %.

Has the business concern previously been the subject of a formal SBA size determination? [ ] yes [ ] no

If yes, identify the SBA office, the determination date, and provide a copy of the determination.

___________________________________________________________________________________

Business concern is owned by: [ ] AIT [ ] ANC [ ] CDC [ ] NHO [ ] Individual(s)

Name of AIT/ANC/CDC/NHO Owner: ___________________________________________________

Section II

Business Management and Administration

Provide the following information on all individuals who are owners, directors, management members, partners and officers

(Add additional pages if necessary)

Name	Position in Business concern	Percentage of Ownership Interest in Business Concern	Hours Per Week Devoted to the Management of Business Concern	Socially Disadvantaged (Y/N)	Economically Disadvantaged (Y/N)

If the “Percentage of Ownership Interests” identified do not total 100% because a certain percentage of the applicant concern is owned by a another business concern or other organization, identify those owners in your response to Question Number 6 below.

Note: You must attach a detailed explanation, including supporting documentation, noting the question number for each “yes” response to the following questions 1 -20.

Is the business concern delinquent in filing any applicable business tax returns?	[ ]Yes	[ ]No
Does the business concern have any past due taxes or any other delinquent Federal, state or local financial obligations outstanding or liens filed against it? If yes, provide information about any tax liens or unsatisfied judgments, evidence of repayment arrangements and proof of compliance with repayment arrangements.	[ ]Yes	[ ]No
Does the business concern have any existing management, joint venture, indemnity, consulting, distributorship, licensing, trust or franchise agreements? If yes, include copies of these agreements.	[ ]Yes	[ ]No
Have there been any changes in ownership of the business concern in the past two years? If yes, identify prior owners by name, percentage of ownership, and dates of ownership.	[ ]Yes	[ ]No
Does the business concern have an ownership interest in, or an affiliation with (see definition of “affiliation” on page 1), any other business concern? If yes, for each affiliate and/or subsidiary provide the seven categories of information listed in question 6.	[ ]Yes	[ ]No
Does any other business concern or other organization have an ownership interest in the business concern? If yes, provide for each business concern or organization the following information: (1) the name and address; (2) the type of business or organization; (3) the names of every owner, director, and officer; (4) if the owner is a business concern, the Primary NAICS code; (5) the nature of the entity’s relationship with the applicant business concern; (6) the percentage of ownership of the applicant business concern; and (7) a statement as to whether the other business concern is a current or former 8(a) BD program participant.	[ ]Yes	[ ]No
Does the business concern buy from, sell to, or use the services or facilities of any other business concern, or otherwise conduct business with any other business concern, in which a principal of the applicant business concern has a financial or any other interest? If yes, provide the name of the other business concern, the name of that concern’s president or CEO, the name(s) of the principal(s) of that concern, and type of interest.	[ ]Yes	[ ]No
Has the business concern previously applied and been approved for the 8(a) BD Program or SDB certification? If yes, provide the dates of participation in the 8(a) BD program or as an SDB, reason for ending participation (e.g., graduation, termination), and SBA servicing office of record.	[ ]Yes	[ ]No
Does (or do) any outside entity(ies) or individual(s) provide financial or bonding support, licenses or required professional certification, office space or equipment to the applicant business concern? If yes, provide the name of the entity(ies) or individual(s), the nature of assistance (in the case of licenses and professional certifications, include the type of license and/or certification) and copies of any existing agreements governing that relationship.	[ ]Yes	[ ]No
Does anyone other than an economically and socially disadvantaged individual (see discussion in Individual Information Form 1010-IND) hold the highest position in the business concern (President/CEO, Managing Member, Managing Partner, Sole Proprietor)?	[ ]Yes	[ ]No
Does any employee, owner, director, officer, partner or management member who is not economically and socially disadvantaged receive compensation or dividends from the applicant business concern that exceeds the compensation of the highest ranking individual of the business concern?	[ ]Yes	[ ]No
Did a third party (person or entity) not employed by the applicant business concern complete or help the business concern complete this form (e.g., attorney, accountant, appraiser, agent, or other representative)? If yes, complete SBA Form 1010-REP and submit it with your application materials.	[ ]Yes	[ ]No
Is the applicant business concern a party to any pending civil lawsuit? If yes, summarize its interest in the suit, a summary of the claims, the current status, and provide a copy of the complaint filed in the suit.	[ ]Yes	[ ]No

Only Business Concerns Applying to the 8(a) BD Program Must Answer the Following Questions:

Has the business concern previously received an SBA loan, or has the business concern ever been an owner, stockholder or guarantor for another business concern which has received an SBA loan? If yes, provide the loan recipient’s name, date approved, and current status of the loan.	[ ]Yes	[ ]No
Has the business concern filed for bankruptcy or insolvency in the past 7 years? If yes, provide details and a copy of the bankruptcy court’s final order.	[ ]Yes	[ ]No
Does the business concern own any assets of a previously certified 8(a) BD Program participant? If yes, provide the business name of the previous 8(a) BD Program participant, name and title of individual(s) claiming disadvantage for previous participant, address of previous participant business concern, dates of participation, and SBA servicing office of record.	[ ]Yes	[ ]No
Does the business concern have a negative net worth or working capital position?	[ ]Yes	[ ]No
Does the individual holding the business concern’s highest position devote less than full-time to the operation of the applicant business concern?	[ ]Yes	[ ]No
Has the business concern earned revenues in its primary NAICS code for less than the immediate past two years?	[ ]Yes	[ ]No
Has the business concern been in business for less than two years? If yes, you will need to seek SBA’s approval for a waiver of the rule that the business concern must be in business for two years prior to application by submitting information to demonstrate the business concern’s potential for success. Guidance on the two-year waiver rule can be found in 13 C.F.R. 124.107 and the 8(a) and SDB website (see Internet address on page 1). There are different waiver criteria for business concerns owned by i. AIT under 13 C.F.R. 124.109 (c)(6)(ii) ii. NHO under 13 C.F.R. 124.110 (e) iii. CDC under 13 C.F.R. 124.111 (f)	[ ]Yes	[ ]No

SECTION III

Supporting Documentation

ALL applicants for the 8(a) BD Program or for initial SDB certification must provide the documents identified in items (1) – (19) below.

Applicants only seeking recertification as an SDB need not submit items numbered (9) – (19) unless there has been a change in ownership or control since the last certification.

If the requested document does not exist or is not applicable to the applicant business concern, note the number(s) from the list below here: _______________________________________________________________________________

1. Each Person owning 10% or more of the business concern and each Director, Management Member, Partner, and Officer of the business concern must complete the Individual Information Form (Form 1010-IND) and submit all documents required by that form.

2. A list of current and past Federal and non-Federal contracts within the last two years. Include award date, agency name, and a description of work and dollar value.

3. Balance sheet and profit and loss statements that is no older than 90 days from the application date.

4. Copies of the last three years of applicant business concern’s Federal tax returns including schedules and attachments.

5. An executed IRS Form 4506-T, Request for Transcript of Tax Return for business concern’s taxes, as well as an executed form for each business concern identified in response to Question Numbers 5 and 6 in Section II.

6. Copy of the current Certificate of Good Standing (for Corporations and LLCs, if applicable) from state where business concern is incorporated. If business concern conducts business in a state other than where it is incorporated, a copy of the filing as a Foreign Corporation and a current Certificate of Good Standing from that state are required as well.

7. SBA Form 1623, Certification Regarding Debarment, Suspension, and other Responsibility Matters.

8. Copies of the financial statements and Federal tax returns, including all schedules, for each of the three preceding fiscal year-end periods for any business concern identified in response to Question Numbers 5 and 6 in Section II.

9. Copies of all stock certificates (front and back), stock ledger, stock register, transmutation agreements (for community property states), and voting agreements.

10. Copies of the applicant business concern’s governing documents, as applicable:

    1. For Corporations: Articles of Incorporation, Bylaws (include amendments), and past two years of Stockholder and Board Member Meeting Minutes; resolution or other documentation designating officers, directors, and/or general managers as required by the business concern’s governing documents; and documentation authorizing the business concern to seek 8(a) BD certification.

    2. Limited Liability Companies: Articles of Organization, Operating Agreement (including all amendments), and past two years of Member Meeting Minutes; resolution or other documentation designating officers, directors, members representative, management committee members, and/or general managers as required by the business concern’s governing documents; and documentation authorizing the business concern to seek 8(a) BD certification.

    3. Partnerships: Partnership Agreement, and documentation authorizing the business concern to seek 8(a) BD certification.

Note for AIT-owned applicant business concerns: The Articles of Incorporation, Articles of Organization, or the Partnership Agreement must contain express sovereign immunity waiver language, or a “sue and be sued” clause which designates U.S. Federal Courts to be among the courts of competent jurisdiction for all matters relating to SBA’s programs.

11. Copies of Fictitious Business Name Filing.

12. Copies of bank account signature cards.

13. Copies of the business and special licenses under which the business concern operates.

14. Copies of business concern loan agreements, including lines of credit and shareholder loan(s).

15. A brief description and history of the business (including any changes in ownership/management/legal structure or business activity in the past 5 years).

16. Copy of the current lease agreement(s) and/or proof of ownership for all business facilities and equipment.

17. Copies of buy/sell agreements, conditions precedent, conditions subsequent, executory agreements, voting trusts, shareholder agreements or other similar arrangements which may impact the unconditional ownership of the disadvantaged individuals.

18. Current schedule of business insurance declaration pages (e.g., comprehensive, liability, worker’s compensation, etc.).

19. Copies of all management and joint venture agreements, indemnity agreements and consulting agreements, including agreements for assistance in completing this 8(a) BD application.

Business concerns applying for 8(a) BD program must also submit:

• Balance sheets and profit and loss statements for the preceding three (3) fiscal year-end periods.

• A Statement of Bonding limit from the business concern’s surety specifying single job limit and aggregate limit, if applicable.

Business concerns applying only for SDB certification must also submit:

• Balance sheet and profit and loss statement for the preceding fiscal year-end period.

Business concerns applying only for the SDB recertification must also submit:

• The Form 1010-RECERT stating that there has been no change in ownership or control.

Business concerns owned by an AIT, ANC, NHO or CDC must also submit:

• Form 1010-AIT, 1010-ANC, 1010-NHO or 1010-CDC, as applicable.

NOTICE OF CRIMINAL PENALTIES AND ADMINISTRATIVE REMEDIES FOR FALSE STATEMENTS: Under Title 18 U.S.C. § 1001 and Title 15 U.S.C. § 645, any person who misrepresents a business concern’s status as an 8(a) Program participant or SDB concern, or makes any other false statement in order to influence the certification process in any way, or to obtain a contract awarded under the preference programs established pursuant to sections 8(a), 8(d), 9 or 15 of the Small Business Act, or any other provision of Federal Law that reference Section 8(d) for a definition of program eligibility shall be: (1) Subject to fines and imprisonment of up to 5 years, or both, as stated in Title 18 U.S.C. § 1001; (2) Subject to fines of up to $500,000 and imprisonment of up to 10 years, or both, as stated in Title 15 U.S.C. § 645; (3) Subject to civil and administrative remedies, including suspension and debarment; and (4) Ineligible for participation in programs conducted under the authority of the Small Business Act.

Read the following paragraphs carefully. Your signature below indicates acceptance and understanding of these conditions.

1. Payment of any fee or gratuity to SBA employees is illegal and will subject the parties of such a transaction to prosecution.

2. Applicant agrees to allow SBA access and the right to examine corporate records including, but not limited to, books, documents, papers and other material considered by SBA to be necessary.

3. SBA, in its sole discretion, may at any time request clarification of information contained in this application or any other documents submitted as part of the application process, and may request additional information or documents as it deems appropriate to complete its review of the application.

4. If the applicant business concern fails to provide any requested information or documents, SBA may presume that disclosure of the information would demonstrate that the business concern is not eligible for 8(a) BD Program or SDB certification.

CERTIFICATIONS: By signing this form, I certify that I have reviewed the response to every question on this form and all supporting documents required by this form, and that all responses and documents are true and complete to the best of my knowledge, and that I understand that SBA is relying on this information in making its determination of my company’s eligibility for 8(a) BD Program or SDB certification.

Form must be signed by President/CEO/Proprietor/Management Member/General Partner.

___________________________ ________________________ __________________

Signature Print Name Date

PLEASE NOTE: The estimated burden for completing this form is 2.5 Hours per response. You are not required to respond to any collection of information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to U.S. Small Business Administration, Chief, AIB, 409 3rd St., S.W., Washington D.C. 20416.

REPRESENTATIVES AND FEES

It is not necessary for an applicant business concern to retain representation to assist in the preparation and presentation of this or any other 8(a) BD Program or SDB application. However, if the applicant business concern retains such representation, SBA will determine the reasonableness of fees or other compensation for services actually performed by representatives.

The compensation received by an agent or representative for assisting the applicant business concern in obtaining 8(a) BD Program or SDB certification must be reasonable in light of the services performed by the agent or representative. The fee charged by any agent or representative for assisting the applicant in obtaining 8(a) BD Program or SDB certification cannot be contingent upon the applicant receiving certification.

List the names of attorneys, accountants, appraisers, agents or other representatives who assisted in the preparation or filing of the application. Indicate the amount of fees, bonuses, commissions or expenses paid or due. SBA reserves the right to require, at a later date, a full itemization by representatives of actual services rendered. Attach additional pages if necessary.

NAME AND OCCUPATION OF REPRESENTATIVE	DESCRIPTION OF SERVICES	TOTAL FEES PAID OR DUE

CERTIFICATION: By signing this form, we certify under penalty of criminal prosecution that all information on this form and any attached additional pages, and all responses on the application, including all supporting documents, is true and complete to the best of our knowledge, and that we understand that SBA is relying on this information in making its determination of the reasonableness of the fees charged and the applicant business concern’s eligibility for 8(a) BD Program or SDB certification.

Applicant:

___________________________ ________________________ __________________

Signature Print Name Date

(President/CEO/Proprietor/Management Member/General Partner)

Representative(s)

(1) ___________________________ ________________________ __________________

Signature Print Name Date

Name of Employer: _________________________________________________________________

(2) ___________________________ ________________________ __________________

Signature Print Name Date

Name of Employer: _________________________________________________________________

(3) ___________________________ ________________________ __________________

Signature Print Name Date

Name of Employer: _________________________________________________________________

PLEASE NOTE: The estimated burden for completing this form is .5 Hours per response. You are not required to respond to any collection of information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to U.S. Small Business Administration, Chief, AIB, 409 3rd St., S.W., Washington D.C. 20416.

INDIVIDUAL INFORMATION

Each person owning 10% or more of the applicant business concern and each director, management member, partner, and officer of the applicant business concern must complete this form and attach the documents required below.

YOUR SIGNATURE ON THIS FORM INDICATES THAT YOU FULLY UNDERSTAND ALL QUESTIONS AND CERTIFIES THAT ALL RESPONSES AND DOCUMENTS ARE TRUTHFUL AND ACCURATE.

Name: ___________________________________ Gender: [ ] Male [ ] Female

Home Address: _______________________________________________________________________

City: _____________________ County: _____________ State: ______________ Zip: ______________

Name of Applicant Business concern (include any trade or d.b.a. names): ___________________________________________________________________________________________

Your Position(s) in the Business concern: Director [ ] Partner [ ] Owner [ ] percentage owned:_________

Officer [ ] position(s) ____________________________ Other: ____________________________________

Average Number of Hours per Week Devoted to Working at the Business concern: ________

Are you authorized to make withdrawals from, or have access to, the business concern’s bank account?

[ ] Yes [ ] No

Note: You must attach a detailed explanation, including supporting documentation, noting the question number for each “yes” response to the following questions 1 - 12.

Have you filed for personal bankruptcy in the past 7 years? If yes, provide details and a copy of the bankruptcy court’s final order or discharge.	[ ]Yes	[ ]No
Have you previously obtained an SBA loan? If yes, provide the name(s) of the borrower(s) on the loan, date approved, and current status of the loan.	[ ]Yes	[ ]No
Have you ever been an owner, stockholder, or guarantor for a business concern which has received an SBA loan? If yes, provide the name(s) of the borrower(s) on the loan, date approved, and current status of the loan.	[ ]Yes	[ ]No
Are you a party to any pending civil lawsuit? If yes, summarize your interest in the suit, a summary of the claims, and the current status of the suit.	[ ]Yes	[ ]No
Are you a former employer or an officer of a former employer, of any individual(s) claiming disadvantage?	[ ]Yes	[ ]No
Other than any publicly traded stock, bonds, and mutual funds you may own, do you have an ownership interest in any other business, and/or are you an officer or director in any other business concern? If yes, provide the following information: (1) identify your percentage of ownership in that(those) concern’s (s’); (2) identify the number of employees in that(those) concern(s); (3) identify that(those) concern(s) revenues for the past three years; and (4) identify all other owners, partners, directors, officers, and principal stockholders in that(those) concern(s) by name, address, position held, and percentage of any ownership interest.	[ ]Yes	[ ]No
Are you, or is any member of your household, a Federal employee?	[ ]Yes	[ ]No
Were you born outside of the United States? If yes, provide evidence of U.S. citizenship.	[ ]Yes	[ ]No
Do you have any delinquent Federal obligations, past due taxes or liens or have you been delinquent in filing your personal Federal or local tax returns? If yes, your explanation must include a discussion of and copies of any tax liens or unsatisfied judgments, evidence of repayment arrangements and proof of compliance with repayment arrangements.	[ ]Yes	[ ]No
Have you previously used your socially disadvantaged status to qualify a business concern for the 8(a) BD Program or have you ever been an owner (full or partial), director, officer or partner in another business concern that was admitted to the 8(a)/BD program? If yes, your narrative statement must include the name of the other business concern and describe the percentage of any ownership interest in that business concern.	[ ]Yes	[ ]No
Has an immediate family member (see definition on Form 1010) ever been an owner (full or partial) of another business concern that was admitted to the 8(a)/BD program? If yes, your narrative statement must include the name of the business concern and describe the percentage of any ownership interest.	[ ]Yes	[ ]No
Have you ever been debarred, suspended, voluntarily excluded or otherwise the subject of an action that rendered you ineligible for procurement or non-procurement purposes from any department or agency of the Federal Government? If yes, provide a brief description of the cause of action.	[ ]Yes	[ ]No

All persons signing this form must provide the following documents:

• Personal Resume, including the education, technical training and business and employment experience (employer’s name, dates of employment and nature of employment). Your resume must include a description of your current duties within the applicant business concern.

• Copies of your personal Federal income tax returns (including all schedules and W-2 forms) for the two years immediately preceding the application for yourself and your spouse (if filing separately), and an executed IRS form 4506-T, Request for Transcript of Tax Return, for yourself and your spouse (if filing separately).

Note for AIT- or ANC-owned business concerns: Only individuals owning 10% or more of the applicant business concern need to submit two years of Federal income tax returns.

• 8(a) Applications Only: A completed SBA Form 912, “Statement of Personal History,” (include required Form FD-258, Fingerprint Card, for affirmative answers to questions 7, 8, and 9 on the SBA Form 912), a narrative providing all details for each arrest/incident, and copies of any available court disposition(s)/document(s).

Additionally, persons claiming to be socially and economically disadvantaged in order to qualify the applicant business concern for the 8(a) BD Program or for SDB Certification must answer questions 13 – 15 and provide the documents listed below:

Have you transferred any personal assets during the last two years to any immediate family member for less than fair market value? If yes, provide a detailed explanation, including the nature and amount of the asset(s) transferred and the recipient of each transferred asset.	[ ]Yes	[ ]No
Are you currently employed outside the applicant business concern? If yes, provide information on this employment and evidence that the activity does not conflict with the day-to-day management of the applicant business concern. Please indicate the number of hours per week and the normal working hours of this outside employment.	[ ]Yes	[ ]No
Identify which of the following presumed socially disadvantaged group(s) you are in (you should review 13 C.F.R. § 124.103(b) before answering): Black American [ ] Hispanic American [ ] Native American [ ] Asian Pacific American [ ] Subcontinent Asian Americans [ ] None of the above [ ] (If non of the above, follow instructions on next page) If Native American, identify whether Federally or state recognized Indian tribe and indicate tribal card number:_________________________________________________________________________________ If you answered “none of the above” to question 15, you are not presumed to be socially disadvantaged, and you must provide a narrative statement – and evidence – demonstrating discriminatory treatment sufficient to meet the social disadvantage requirement. See 13 C.F.R. § 124.103 and the 8(a) BD and SDB website (see Internet address on page 1 of the Form 1010).

• A narrative statement describing your economic disadvantage. See 13 C.F.R. § 124.104.

• A completed SBA Form 413, “Personal Financial Statement,” no older than 30 days, for the individual claiming disadvantage and a separate SBA Form 413 for his/her spouse, dividing all assets and liabilities as appropriate. If the individual claiming disadvantage is married and lives in a community property state, evidence of which assets and income are community property and which are separate must be provided.

NOTICE OF CRIMINAL PENALTIES AND ADMINISTRATIVE REMEDIES FOR FALSE STATEMENTS: Under Title 18 U.S.C. § 1001 and Title 15 U.S.C. § 645, any person who misrepresents a business concern’s status as an 8(a) Program participant or SDB concern, or makes any other false statement in order to influence the certification process in any way, or to obtain a contract awarded under the preference programs established pursuant to section 8(a), 8(d), 9 or 15 of the Small Business Act, or any other provision of Federal Law that reference Section 8(d) for a definition of program eligibility shall be: (1) Subject to fines and imprisonment of up to 5 years, or both, as stated in Title 18 U.S.C. § 1001; (2) subject to fines of up to $500,000 and imprisonment of up to 10 years, or both, as stated in Title 15 U.S.C. § 645; (3) Subject to civil and administrative remedies, including suspension and debarment; and (4) Ineligible for participation in programs conducted under the authority of the Small Business Act.

CERTIFICATIONS: By signing this form, I certify that

• I have reviewed the responses to all questions on this form and all supporting documents required by this form, and that all responses and documents are true and complete to the best of my knowledge.

• I understand that SBA is relying on this information in making its determination of my company’s eligibility for the 8(a) BD Program or SDB certification.

• I have not previously used my socially and economically disadvantaged status to qualify another company for the 8(a) BD Program.

___________________________ ________________________ __________________

Signature Print Name Date

PLEASE NOTE: The estimated burden for completing this form is 2.5 Hours per response. You are not required to respond to any collection of information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to U.S. Small Business Administration, Chief, AIB, 409 3rd St., S.W., Washington D.C. 20416.

American Indian Tribe Information

The American Indian Tribe that owns at least 51 percent of the applicant business concern

must complete this form. 13 C.F.R. § 124.109(b).

YOUR SIGNATURE ON THIS FORM INDICATES THAT YOU FULLY UNDERSTAND ALL QUESTIONS AND CERTIFIES THAT ALL RESPONSES AND DOCUMENTS ARE TRUTHFUL AND ACCURATE.

Name of Applicant Business Concern (include any trade or d.b.a. names): ________________________________________________________________________________________

Name of American Indian Tribe (AIT): _________________________________________

Note: AIT means any Indian tribe, band, nation, or other organized group or community of Indians, which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians, or is recognized as such by the State in which the tribe, band, nation, group, or community resides. 13 C.F.R. § 124.3.

Telephone: ( )____________________ Fax: ( )_________________________

Address: _______________________________________________________________________

City: _____________________ County: _____________ State: ______________ Zip: ______________

E-mail: __________________________________________ @ ____________________________

Mailing Address (if different from above)

Address: _____________________________________________________________________

City: _____________________ State: ______________ Zip: ______________

Indian Tribe percent ownership of applicant business concern: ___________

Please answer the following questions and provide the required documents:

Has the Tribe previously established its economic disadvantaged status under the 8(a) BD Program? If yes, provide a copy of the SBA determination. If no, provide the following information for the tribe: The number of tribal members. The present tribal unemployment rate. The per capita income of tribal members, excluding judgment awards. The percentage of the local Indian population below the poverty level. The tribe’s access to capital markets. The tribe’s assets as disclosed in the current tribal financial statement, including those which are encumbered or held in trust; the status of assets encumbered or in trust must be clearly delineated.	[ ]Yes	[ ]No
Does the Tribe or subsidiary of the Tribe own 50% or more of another business concern other than the applicant business concern? If yes, identify the names of any other business concern(s), the primary NAICS code of the other business concern(s), and which (if any) of the other business concerns have ever participated in the 8(a) BD Program.	[ ]Yes	[ ]No
Does the Tribe own the applicant concern directly (rather than through a subsidiary)?	[ ]Yes	[ ]No
Does the Tribe own the applicant business concern through a subsidiary? If yes, provide the name and address of that subsidiary.	[ ]Yes	[ ]No
Is a tribal member the highest officer or designated manager of the applicant business concern? If yes, provide evidence of tribal membership. If no, provide a copy of the tribal management development plan.	[ ]Yes	[ ]No

Please provide the following documents

• Evidence of the tribe’s recognition as a tribe eligible for the special programs and services provided by the United States or by the Tribe’s state of residence.

• Documentation showing the AIT’s ownership of the applicant business concern.

• Copies of all governing documents, such as the tribe’s constitution or business charter.

• Copies of the tribe’s articles of incorporation and bylaws as filed with the organizing or chartering authority, or similar documents needed to establish and govern a non-corporate legal entity.

NOTICE OF CRIMINAL PENALTIES AND ADMINISTRATIVE REMEDIES FOR FALSE STATEMENTS: Under Title 18 U.S.C. § 1001 and Title 15 U.S.C. § 645, any person who misrepresents a business concern’s status as an 8(a) Program participant or SDB concern, or makes any other false statement in order to influence the certification process in any way, or to obtain a contract awarded under the preference programs established pursuant to section 8(a), 8(d), 9 or 15 of the Small Business Act, or any other provision of Federal Law that reference Section 8(d) for a definition of program eligibility shall be: (1) Subject to fines and imprisonment of up to 5 years, or both, as stated in Title 18 U.S.C. § 1001; (2) subject to fines of up to $500,000 and imprisonment of up to 10 years, or both, as stated in Title 15 U.S.C. § 645; (3) Subject to civil and administrative remedies, including suspension and debarment; and (4) Ineligible for participation in programs conducted under the authority of the Small Business Act.

CERTIFICATIONS: By signing this form, I certify that all information in this application, including all supporting documents, is true and complete to the best of my knowledge, and that I understand that SBA is relying on this information in making its determination of my company’s eligibility for 8(a) BD Program or SDB certification.

Form must be signed by the Tribal Chief.

___________________________ ________________________ __________________

Signature Print Name Date

PLEASE NOTE: The estimated burden for completing this form is 1 Hour per response. You are not required to respond to any collection of information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to U.S. Small Business Administration, Chief, AIB, 409 3rd St., S.W., Washington D.C. 20416.

Alaska Native Corporation Information

The Alaska Native Corporation that owns the applicant business concern

must complete this form. 13 C.F.R. § 124.109(a).

YOUR SIGNATURE ON THIS FORM INDICATES THAT YOU FULLY UNDERSTAND ALL QUESTIONS AND CERTIFIES THAT ALL RESPONSES AND DOCUMENTS ARE TRUTHFUL AND ACCURATE.

Name of Applicant Business Concern (include any trade or d.b.a. names): _____________________________________________________________________________________

Name of Parent Alaska Native Corporation (ANC): _________________________________________

Note: An ANC means any Regional Corporation, Village Corporation, Urban Corporation, or Group Corporation organized under the laws of the State of Alaska in accordance with the Alaska Native Claims Settlement Act, as amended 43 U.S.C. 1601, et seq. 13 C.F.R. § 124.3.

Telephone: ( )____________________ Fax: ( )_________________________

Address: _______________________________________________________________________

City: _____________________ County: _____________ State: ______________ Zip: ______________

E-mail: __________________________________________ @ ____________________________

Mailing Address (if different from above)

Address: _____________________________________________________________________

City: _____________________ State: ______________ Zip: ______________

ANC percent ownership of applicant business concern: ___________

Please answer the following questions and provide the required documents:

Does the ANC or subsidiary of the ANC own 50% or more of another business concern other than the applicant business concern? If yes, identify the names of any other business concern(s), the primary NAICS code of the other business concern(s), and which (if any) of the other business concerns have ever participated in the 8(a) BD Program.	[ ]Yes	[ ]No
Does the ANC own the applicant business concern directly (rather than through a subsidiary)?	[ ]Yes	[ ]No
Does the ANC own the applicant business concern through a subsidiary(ies)? If yes, provide the name(s) and address(es) for the concern(s).	[ ]Yes	[ ]No

Please provide the following documents:

• Copy of the ANC’s Articles of Incorporation and Bylaws (including any amendments).

• Copies of the governing documents of the subsidiary(ies) identified in Question 3 above.

• For Corporations: Articles of Incorporation, Bylaws (including any amendments), and stock certificates and register.

• For Limited Liability Companies: Articles of Organization and Operating Agreement (including all amendments).

• Copies of minutes or other documentation from the ANC and/or the business concerns identified in Question 3 above that relate to the applicant business concern (e.g., delegation of authority, designation of representatives or directors, authorization for capitalization and/or formation, etc.).

• Copies of Federal tax returns, including all schedules, filed for the past three years for the ANC and any business concern identified in Question 3 above.

• Copies of the balance sheet and profit and loss statement for each of the three most recent fiscal year-end periods, signed, certified, and dated by the highest managing individual for the ANC and any business concern identified in Question 3 above.

NOTICE OF CRIMINAL PENALTIES AND ADMINISTRATIVE REMEDIES FOR FALSE STATEMENTS: Under Title 18 U.S.C. § 1001 and Title 15 U.S.C. § 645, any person who misrepresents a business concern’s status as an 8(a) Program participant or SDB concern, or makes any other false statement in order to influence the certification process in any way, or to obtain a contract awarded under the preference programs established pursuant to section 8(a), 8(d), 9 or 15 of the Small Business Act, or any other provision of Federal Law that reference Section 8(d) for a definition of program eligibility shall be: (1) Subject to fines and imprisonment of up to 5 years, or both, as stated in Title 18 U.S.C. § 1001; (2) subject to fines of up to $500,000 and imprisonment of up to 10 years, or both, as stated in Title 15 U.S.C. § 645; (3) Subject to civil and administrative remedies, including suspension and debarment; and (4) Ineligible for participation in programs conducted under the authority of the Small Business Act.

CERTIFICATIONS: By signing this form, I certify that all information in this application, including all supporting documents, is true and complete to the best of my knowledge, and that I understand that SBA is relying on this information in making its determination of my company’s eligibility for 8(a) BD Program or SDB certification.

Form must be signed by the ANC’s President or CEO.

___________________________ ________________________ __________________

Signature Print Name Date

PLEASE NOTE: The estimated burden for completing this form is 1 Hour per response. You are not required to respond to any collection of information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to U.S. Small Business Administration, Chief, AIB, 409 3rd St., S.W., Washington D.C. 20416.

Native Hawaiian Organization Information

The Native Hawaiian Organization that owns the applicant business concern

must complete this form. 13 C.F.R. § 124.110.

YOUR SIGNATURE ON THIS FORM INDICATES THAT YOU FULLY UNDERSTAND ALL QUESTIONS AND CERTIFIES THAT ALL RESPONSES AND DOCUMENTS ARE TRUTHFUL AND ACCURATE.

Name of Applicant Business Concern (include any trade or d.b.a. names): _______________________________________________________________________________________

Name of Parent Native Hawaiian Organization (NHO): _________________________________________ Note: An NHO means any community service organization serving Native Hawaiians in the State of Hawaii which is a non-profit corporation that has filed articles of incorporation with the Director (or the designee thereof) of the Hawaii Department of Commerce and Consumer Affairs, or any successor agency, is controlled by Native Hawaiians, and whose business activities will principally benefit such Native Hawaiians. 15 U.S.C. § 637(a)(15).

Telephone: ( )____________________ Fax: ( )_________________________

Address: _______________________________________________________________________

City: _____________________ County: _____________ State: ______________ Zip: ______________

E-mail: __________________________________________ @ ____________________________

Mailing Address (if different from above)

Address: _____________________________________________________________________

City: _____________________ State: ______________ Zip: ______________

NHO percent ownership of applicant business concern: ___________

Provide the following information on each NHO member, director, and officer

(Add additional pages if necessary)

Name	Position in NHO	Native Hawaiian (Y/N)	Economically Disadvantaged (Y/N)	U.S. Citizen (Y/N)

Please answer the following questions and provide the required documents:

Does the NHO or subsidiary of the NHO own 50% or more of another business concern other than the applicant business concern? If yes, identify the names of any other business concern(s), the percentage of the NHO’s ownership, the names of the individuals who manage and control it by serving as officers, directors, or managers, the primary NAICS code of the other business concern(s), and which (if any) of the other business concerns have ever participated in the 8(a) BD Program.	[ ]Yes	[ ]No
Has the NHO ever been an owner, stockholder or guarantor for a concern which has received an SBA loan?	[ ]Yes	[ ]No

Please provide the following documents:

• The NHO’s directors, members, officers, key managers, individuals claiming disadvantaged status, and any hired manager(s) with authority to speak for and commit the NHO must complete and submit the Individual Information form (See Form 1010-IND).

• NHO’s Balance sheet and profit and loss statement for the preceding three (3) fiscal year-end periods. These should be signed, certified, and dated by the NHO’s highest managing individual.

• Copy of the NHO’s corporate bylaws.

• Signed copies of the NHO’s Federal tax returns, including all schedules, filed for the past three years, if applicable.

• Copy of the birth certificates of those NHO members/directors who claim to be Native Hawaiian.

• Documentation which demonstrates the legal status of the NHO, including the pertinent documentation filed with the State of Hawaii’s Department of Commerce and Consumer Affairs.

• Copies of all minutes of NHO board of directors meetings and all resolutions of the board of directors for the past two years.

• Copies of all minutes of NHO members meetings showing the election of directors.

• Documentation showing the NHO’s ownership of the applicant business concern.

NOTICE OF CRIMINAL PENALTIES AND ADMINISTRATIVE REMEDIES FOR FALSE STATEMENTS: Under Title 18 U.S.C. § 1001 and Title 15 U.S.C. § 645, any person who misrepresents a business concern’s status as an 8(a) Program participant or SDB concern, or makes any other false statement in order to influence the certification process in any way, or to obtain a contract awarded under the preference programs established pursuant to section 8(a), 8(d), 9 or 15 of the Small Business Act, or any other provision of Federal Law that reference Section 8(d) for a definition of program eligibility shall be: (1) Subject to fines and imprisonment of up to 5 years, or both, as stated in Title 18 U.S.C. § 1001; (2) subject to fines of up to $500,000 and imprisonment of up to 10 years, or both, as stated in Title 15 U.S.C. § 645; (3) Subject to civil and administrative remedies, including suspension and debarment; and (4) Ineligible for participation in programs conducted under the authority of the Small Business Act.

CERTIFICATIONS: By signing this form, I certify that all information in this application, including all supporting documents, is true and complete to the best of my knowledge, and that I understand that SBA is relying on this information in making its determination of my company’s eligibility for 8(a) BD Program or SDB certification.

Form must be signed by the NHO’s President or CEO.

___________________________ ________________________ __________________

Signature Print Name Date

PLEASE NOTE: The estimated burden for completing this form is 1 Hour per response. You are not required to respond to any collection of information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to U.S. Small Business Administration, Chief, AIB, 409 3rd St., S.W., Washington D.C. 20416.

Community Development Corporation Information

The Community Development Corporation that owns the applicant business concern

must complete this form. 13 C.F.R. § 124.111.

YOUR SIGNATURE ON THIS FORM INDICATES THAT YOU FULLY UNDERSTAND ALL QUESTIONS AND CERTIFIES THAT ALL RESPONSES AND DOCUMENTS ARE TRUTHFUL AND ACCURATE.

Name of Applicant Business Concern (include any trade or d.b.a. names): ______________________________________________________________________________________

Name of Parent Community Development Center (CDC): _________________________________________

Note: A CDC means a nonprofit organization responsible to residents of the area it serves which has received financial assistance under 42 U.S.C. 9805, et seq. 13 C.F.R. § 124.3.

Telephone: ( )____________________ Fax: ( )_________________________

Address: _______________________________________________________________________

City: _____________________ County: _____________ State: ______________ Zip: ______________

E-mail: __________________________________________ @ ____________________________

Mailing Address (if different from above)

Address: _____________________________________________________________________

City: _____________________ State: ______________ Zip: ______________

CDC percent ownership of applicant: ___________

Please answer the following questions and provide the required documents:

Does the CDC or subsidiary of the CDC own 50% or more of another business concern other than the applicant business concern? If yes, identify the names of any other business concern(s), the primary NAICS code of the other business concern(s), and which (if any) of the other business concerns have ever participated in the 8(a) BD Program.	[ ]Yes	[ ]No
Does the CDC own the applicant concern directly (rather than through a subsidiary)?	[ ]Yes	[ ]No
Does the CDC own the applicant business concern through a subsidiary? If yes, provide the name and address of that subsidiary.	[ ]Yes	[ ]No

Please provide the following documents:

• Documentation which demonstrates the legal status of the CDC.

• Documentation showing the CDC’s ownership of the applicant business concern.

NOTICE OF CRIMINAL PENALTIES AND ADMINISTRATIVE REMEDIES FOR FALSE STATEMENTS: Under Title 18 U.S.C. § 1001 and Title 15 U.S.C. § 645, any person who misrepresents a business concern’s status as an 8(a) Program participant or SDB concern, or makes any other false statement in order to influence the certification process in any way, or to obtain a contract awarded under the preference programs established pursuant to section 8(a), 8(d), 9 or 15 of the Small Business Act, or any other provision of Federal Law that reference Section 8(d) for a definition of program eligibility shall be: (1) Subject to fines and imprisonment of up to 5 years, or both, as stated in Title 18 U.S.C. § 1001; (2) subject to fines of up to $500,000 and imprisonment of up to 10 years, or both, as stated in Title 15 U.S.C. § 645; (3) Subject to civil and administrative remedies, including suspension and debarment; and (4) Ineligible for participation in programs conducted under the authority of the Small Business Act.

CERTIFICATIONS: By signing this form, I certify that all information in this application, including all supporting documents, is true and complete to the best of my knowledge, and that I understand that SBA is relying on this information in making its determination of my company’s eligibility for 8(a) BD Program or SDB certification.

Form must be signed by the CDC’s President or CEO.

___________________________ ________________________ __________________

Signature Print Name Date

PLEASE NOTE: The estimated burden for completing this form is 1 Hour per response. You are not required to respond to any collection of information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to U.S. Small Business Administration, Chief, AIB, 409 3rd St., S.W., Washington D.C. 20416.

STATEMENT FOR RECERTIFICATION AS AN SMALL DISADVANTAGED BUSINESS (SDB)

YOUR SIGNATURE ON THIS FORM INDICATES THAT YOU FULLY UNDERSTAND ALL QUESTIONS AND CERTIFIES THAT ALL RESPONSES AND DOCUMENTS ARE TRUTHFUL AND ACCURATE.

Name of Applicant Business Concern (include any trade or d.b.a. names): __________________________________________________________________________________________

If applicable, Name of Tribe, ANC, NHO, or CDC: ________________________________________________

NOTICE OF CRIMINAL PENALTIES AND ADMINISTRATIVE REMEDIES FOR FALSE STATEMENTS: Under Title 18 U.S.C. § 1001 and Title 15 U.S.C. § 645, any person who misrepresents a business concern’s status as an 8(a) Program participant or SDB concern, or makes any other false statement in order to influence the certification process in any way, or to obtain a contract awarded under the preference programs established pursuant to section 8(a), 8(d), 9 or 15 of the Small Business Act, or any other provision of Federal Law that reference Section 8(d) for a definition of program eligibility shall be: (1) Subject to fines and imprisonment of up to 5 years, or both, as stated in Title 18 U.S.C. § 1001; (2) subject to fines of up to $500,000 and imprisonment of up to 10 years, or both, as stated in Title 15 U.S.C. § 645; (3) Subject to civil and administrative remedies, including suspension and debarment; and (4) Ineligible for participation in programs conducted under the authority of the Small Business Act.

CERTIFICATIONS: By signing this form, I certify that, to the best of my knowledge, there has been no change in the ownership or operational control over the applicant business concern since the date of the business concern’s last certification as an SDB, including since the applicant business concern exited the 8(a) program, and that I understand that SBA is relying on this information in making its determination of my company’s eligibility for SDB recertification.

Form must be signed by the business concern’s President/CEO/Proprietor/Management Member/General Partner.

___________________________ ________________________ __________________

Signature Print Name Date

11

SBA Form 1010 (05/08)