Sba Form 1010-anc Alaska Native Corporation Information

OMB Approval No. 3245-0331

Expiration Date: xx/xx/xxxx

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 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 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.

SBA Form 1010-ANC (-)