Form SBA Form 1010 AIT SBA Form 1010 AIT The American Indian Tribe Information

Approval No. OMB 3245-0331

_{Expiration Date: 04/30/2017}

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. Please submit this form with the 8(a) Business Development Program Application – SBA Form 1010. The information will be used as part of the program eligibility determination.

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:}

1. 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

[ ]Yes [ ]No

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.

2. 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.

3. Does the Tribe own the applicant concern directly (rather than through a subsidiary)?

4. Does the Tribe own the applicant business through a subsidiary? If yes, provide the name and address of that subsidiary.

5. 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.

_{Please provide the following documents}

[ ]Yes [ ]No

[ ]Yes [ ]No [ ]Yes [ ]No [ ]Yes [ ]No

 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

The estimated burden for completing this form, including reading the instructions and gathering the information, is 1 hour for initial application and each annual update. (A submission for reconsideration is estimated to require approximately 30 minutes). 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, and/or SBA Desk Officer, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503. PLEASE DO NOT SEND FORMS TO OMB.

SBA Form 1010 – AIT (3/11)