Form SBA FORM 1010-NHO SBA FORM 1010-NHO NATIVE HAWAIIAN ORGANIZATION INFORMATION

OMB Approval No. 3245-0331

Expiration Date: xx/xx/xxxx

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 other than the applicant business? 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 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.

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.

SBA Form 1010-NHO (-)