Sba Form 1010-ait American Indian Tribe Information

Approval No. OMB 3245-0331

Expiration Date: xx/xx/xxxx

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 other than the applicant business ? 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 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? 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 firm.

• 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 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 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.

SBA Form 1010 – AIT (-)