Form TD F 100.5 TD F 100.5 Troubled Assets Relief Program (TARP) - Small, Minority,

DEPARTMENT OF TREASURY
TROUBLED ASSETS RELIEF PROGRAM (TARP)
SMALL, MINORITY and WOMEN-OWNED BUSINESS REPORT
(See instructions on reverse)

1. CORPORATION, COMPANY, OR SUBDIVISION COVERED

3. DATE SUBMITTED

a. COMPANY NAME
b. STREET ADDRESS

4. REPORTING PERIOD FROM INCEPTION OF CONTRACT THRU:

MONTH or QUARTER
c. CITY

YEAR

d. STATE e. ZIP CODE
5. TYPE OF REPORT

2. CONTRACTOR IDENTIFICATION NUMBER

a.

6. REPORT SUBMITTED AS (Check one and provide appropriate number)

MONTHLY

FINAL

b.

PRIME CONTRACT NUMBER

PRIME CONTRACTOR
ORIGINAL

SUBCONTRACT NUMBER

SUBCONTRACTOR

PART I - SUBCONTRACT AWARDS
TYPE

7.

SMALL BUSINESS CONCERNS:

7a.

8(a) BUSINESSES

7b.

SMALL DISADVANTAGED BUSINESSES (SDB)

7c.

WOMEN-OWNED SMALL BUSINESSES

7d.

HUBZone SMALL BUSINESSES

7e.

VETERAN-OWNED BUSINESSES

7f.

SERVICE-DISABLED VETERAN -OWNED SMALL
BUSINESSES

8.

MINORITY BUSINESSES:

8a.

AFRICAN AMERICANS (AFA)

8b.

ASIAN AMERICANS (ASA)

8c.

HISPANIC AMERICANS (HIS)

8d.

NATIVE AMERICANS (NAT)

8e.

OTHERS (OTH)_________________________

9.

LARGE BUSINESSES

9a.

MINORITIES

9b.

WOMEN

CURRENT TARGET

WHOLE DOLLARS

PERCENT

100%

100%

100%

REVISED REPORT

ACTUAL CUMULATIVE

WHOLE DOLLARS

PERCENT

PART II - LIST of SUBCONTRACTORS
SUBCONTRACTOR'S
NAME

1st or
2nd

CONTRACTOR
TYPE

DUNS #

AWARD AMOUNT
$$$

TYPE of WORK PERFORMED

PART III - MARKETING and OUTREACH
DATE

TITLE of EVENT

TYPE of OUTREACH

LOCATION

PAGE 2

PART IV - REMARKS

NAME OF POINT of CONTACT for S/MWOB PLAN

E-MAIL ADDRESS

TELEPHONE NUMBER
AREA CODE

NUMBER

PAGE 3

Submit by Email

GENERAL INSTRUCTIONS

1. This report is required for large businesses that have been awarded
contracts under TARP's Financial Agent Authority.
2. This form collects subcontract award data from prime contractors/
subcontractors that have been awarded a contract under the Emergency
Economic Stabilization Act of 2008.
3. This report is required for each contract containing a S/MWOB Plan and
must be submitted to the The Department of Treasury's Office of Small and
Disadvantaged Business (OSDBU's) Director, monthly, during the first quarter
of the contract; a separate report is required for each contract at contract
completion. Monthly reports are due 15 days after the close of each month
unless otherwise directed by the OSDBU. The final report is due 30 days after
contract completion. Reports are required when due, regardless of whether
there has been any subcontracting activity since the inception of the contract
or since the previous report.
4. Only subcontracts involving performance in the U.S. or its outlying areas
should be included in this report.
5. Subcontract award data reported on this form by prime contractors/
subcontractors shall be limited to awards made to their 1st and 2nd tiered
subcontractors.
6. Actual achievements must be reported on the same basis as the targets set
forth in the contract.

BLOCKS 7 through 9: Under "Current Target" enter the dollar and percent in
each category (SB, 8(a), SDB, WOSB, HUBZone, VOSB, Service-Disabled, and
Large and Minority Businesses) from the S/MWOB plan approved for this
contract. (If the original targets agreed upon at contract award have been
revised as a result of contract modifications, please explain in Part IV of this
form. Under "Actual Cumulative," enter actual subcontract achievements
(dollars and percent) from the inception of the contract through the date of
the report shown in Block 4. In cases where indirect costs are included,
the amounts should include both direct awards and an appropriate
prorated portion of indirect awards.
However, the dollar amounts reported under "Actual Cumulative" must be for
the same period of time as the dollar amounts shown under "Current Target."
For a contract with options, the current target should represent the aggregate
target since the inception of the contract. For example, if the contractor is
submitting the report during Option 2 of a multiple year contract, the current
target would be the cumulative target for the base period plus the target for
Option 1 and the target for Option 2.
BLOCK 7a - 7f: Report all subcontracts awarded to SBs, 8(a), SDBs, WOSB,
HUBZones, VOSB, and Service-Disabled VOSB.
BLOCK 8: Report all subcontracts awarded to Minority-Owned Businesses, as
as defined in section 21A(r)(4) of the Federal Home Loan Bank Act (12 U.S.C.
1441a(r)(4).
BLOCK 9: Report all subcontracts awarded to Large (including Women-Owned
and Minority Businesses (including African Americans, Asian Americans,
Hispanic Americans, Native Americans and others deemed by Small Business
Administration.

PART I - SPECIFIC INSTRUCTIONS
PART II - LIST OF SUBCONTRACTORS
BLOCK 2:
For the Contractor Identification Number, enter the nine-digit Data Universal
Numbering System (DUNS) number that identifies the specific contractor
establishment. If there is no DUNS number available that identifies the exact
name and address entered in Block 1, contact Dun and Bradstreet
Information Services at 1-866-705-5711 or via the Internet at http://www.dnb.
com. The contractor should be prepared to provide the following information:
(i) Company legal business name. (ii) Tradestyle, doing business, or other
name by which your entity is commonly recognized. (iii) Company physical
street address, city, state and ZIP Code. (iv) Company mailing address, city,
state and ZIP Code (if separate from physical). (v) Company telephone
number. (vi) Date the company was started. (vii) Number of employees at
your location. (viii) Chief executive officer/key manager. (ix) Line of business
(industry). (x) Company Headquarters name and address (reporting
relationship within your entity).
BLOCK 4: Please indicate month or quarter and year of the reporting period.
BLOCK 5: Please indicate "Monthly", "Quarterly", or "Final" report. Indicate if
it's an original or revised report.
BLOCK 6: Indicate whether the reporting contractor is submitting this report
as a prime contractor or subcontractor and the prime contract or sub- contract
number.

Please list subcontractor's name, as listed in the Central Contractor's
Registration (CCR) database (www.ccr.gov). Indicate whether a first or second
tier sub- contractor. Indicate contractor type as AFA (African American), ASA
(Asian American), HS (Hispanic American), NAT (Native American), OTH
(Other).
PART III - MARKETING AND OUTREACH
Provide a summary of those events sponsored by your organization.
(i.e., in-house counseling, conference, meetings, telephone calls, etc.)
PART IV - REMARKS
Enter a short narrative explanation if targets were not met.