Annual Certification - Qualified Nonprofit Agency Serving People Who Are Severely Disabled

OMB Control Number: 3037-0002

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.

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 are severely disabled and have been employed by the agency doing direct labor in the last fiscal year.

6E. Under blind indicate the number of veterans who have been employed by the agency in the last fiscal year who have blindness as a disability. Under total indicate the number of veterans, including those who are blind, who are severely disabled and have been employed by the agency doing direct labor in the last fiscal year.

7A. Enter the direct labor hours paid to all AbilityOne employees 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 not severely disabled 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, breaking them out for AbilityOne products and services. This total should include vacation, holiday, sick leave pay, and cash health and welfare payments required by the Service Contract Act.

7H. Indicate the total of veterans who are blind or severely disabled from item 7F in the appropriate columns.

7I. Indicate the total amount of wages paid to AbilityOne veterans who are blind or severely disabled. 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. Report only 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.

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; comments may be submitted to Edward Yang, Committee For Purchase From People Who Are Blind or Severely Disabled, Jefferson Plaza 2, Suite 10800, 1421 Jefferson Davis Highway, Arlington, VA 22202-3259; the estimated burden per respondent is six hours and the cost of sending the form to NISH; the OMB approval number is 3037-0002; the expiration date is 03/31/2012.