Certification for the Women-Onwed Small Business Federal Contract Program

Attachment 5
THIRD PARTY CERTIFIER CERTIFICATION FORM
Please read the following certification form statements carefully. The Federal government relies
on the information in this form and any documents or supplemental information submitted to
determine whether the entity should be approved as a Third Party Certifier under the WOSB
Program. The definitions for the terms used in this certification are set forth in the Small
Business Act, SBA regulations (13 C.F.R. Part 127), and also any statutory and regulatory
provisions referenced in those authorities. In addition, please note that the U.S. Small Business
Administration (SBA) may request further clarification or supporting documentation in order to
assist in the verification of any of the information provided and that each person signing this
certification may be prosecuted if they have provided false information. Any action taken with
respect to this certification does not affect the Government’s right to pursue criminal, civil or
administrative remedies for incorrect, incomplete, false or misleading information given, even if
correct information has been included in other materials submitted to SBA.
The undersigned authorized official has reviewed, verified and certifies that (all boxes must be
checked):
General Requirements

The proposed Third Party Certifier meets the following requirements, which establish its
capability to process certification applications from business concerns on a national
basis:
a. A minimum of two years of recent experience (i.e., measured from the date of
submission of the Third Party Certifier Application) certifying businesses at the Federal
or State level for compliance with small, disadvantaged, veteran-owned or womenowned business development or contracting program requirements. Attached is all
relevant information showing that it meets this requirement, including when the entity
started certifying companies, how many it has certified, and the types of certifications issued.

b. Adequate staff with recent experience (i.e., within 2 years of the date of submission of
the Third Party Application) in conducting eligibility reviews of businesses at the
Federal or State level for compliance with small, disadvantaged, veteran-owned or
women-owned business development or contracting program requirements. Attached is
a listing of the staff, by title, job description, and each staff person’s resume, that will be
conducting such eligibility reviews.
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c. A written policy on training its staff on a regular basis, including training on
certification procedures, and how it will address changes to the SBA’s regulations.
Attached is the written policy on training.
Yes

No

The proposed Third Party Certifier will advise the Applicant (the small business that submits an
application to an approved Third Party Certifier for certification as a WOSB or EDWOSB), in
writing and prior to beginning the certification process, that under SBA regulations, the
Applicant may obtain WOSB or EDWOSB certification, at no cost, through the SBA .
Attached is the form of document to be used to advise the Applicant of its right to obtain noncost self-certification under the WOSB program.
Yes

No

The proposed Third Party Certifier has a written policy of rendering fair and impartial EDWOSB
or WOSB certification determinations. The policy states that it will be free of any conflict of
interest with the Applicant and contains procedures for finding and addressing potential conflicts
of interest. Specifically, the policy states that a conflict of interest occurs when a person or
entity has an interest which makes it unable to render impartial assistance or advice, or the
person's or entity’s objectivity in performing is impaired, such as if the proposed Third Party
Certifier or individual reviewing the certification application has a direct or indirect ownership or
control or other financial interest in the Applicant being reviewed. The procedures require the
Third Party Certifiers to conduct due diligence in determining if a conflict of interest exists.
Attached is the written policy.
Yes

No

The proposed Third Party Certifier’s past performance shows that it has rendered fair and
impartial determinations, including but not limited to, having no legal proceedings in which the
entity has been found to have rendered an unfair or partial determination. There is nothing in its
past performance that would tend to show evidence of rendering unfair or partial determinations.
Yes

No

The proposed Third Party Certifier has a written policy of not declining to accept or approve an
application for EDWOSB or WOSB certification on the basis of race, color, national origin,
religion, age, disability, sexual orientation, or marital or family status. Attached is this written
policy.
Yes

No
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The proposed Third Party Certifier will provide SBA with a monthly report by the fifth of each
month identifying the previous month’s activity, including the following information: the
number of WOSB applications received, the number of EDWOSBs applications received, the
total number of applications approved, the total number of applications declined for each type of
application, declination reason(s) with total number per type of application, and the total number
of firms whose status has changed (e.g., ineligible or de- certified) and their unique government
identifier (formerly DUNS); any issues or concerns of fraud, waste and abuse; a statement as to
whether there have been any changes in policy regarding the certification procedures, and, if
there have been any changes, the certifying entity must explain those changes. The report must
also identify the name, address, contact name and telephone number of all the WOSBs and
EDWOSBs which were certified by the Third Party Certifier , as well as whether the firm was certified as a WOSB or
EDWOSB.
Yes

No

The proposed Third Party Certifier will safeguard the confidential information provided by SBA
or the Applicant, and has not had a breach of such confidential information within the last three
years. The proposed Third Party Certifier must sign a confidentiality agreement with each
Applicant stating that it will not release to anyone except the Applicant (and, as appropriate in
the performance of their official functions, SBA and other government officials) any confidential
information received from the Applicant. Attached is the policy on confidential information and
the confidentiality agreement.
Yes

No

The proposed Third Party Certifier will not refer to SBA’s approval of the entity as a Third Party
Certifier in commercial advertising in such a manner as to state or imply that the service
provided is endorsed or preferred by the Federal Government or is considered by the
Government to be superior to other products or services, including self-certification, or that this
Third Party Certification can be used for anything other than the WOSB Program.
Yes

No

The proposed Third Party Certifier may not use the SBA logo, including using the SBA logo as
part of any hyper-link leading to any of its own web pages or sites. It may link to SBA.gov as
long as the descriptive words associated with the link to SBA.gov are accurate and not
misleading and do not misrepresent any relationship between the linking site and SBA.gov.
Advance permission is not required in order to link to SBA.gov provided these conditions are
followed.
Yes

No

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The Certification Process
The proposed Third Party Certifier has a written, clear and objective certification process for
accepting, reviewing, and examining an application for WOSB or EDWOSB certification, as
well as for declining and withdrawing WOSB and EDWOSB certifications. Attached is the
written certification process evidencing each of the requirements below.
Yes

No

The proposed Third Party Certifier’s certification process requires the Applicant to provide the
Third Party Certifier with sufficient information to evaluate whether the Applicant has satisfied
of all of the requirements set forth in 13 C.F.R. part 127.
Yes

No

The proposed Third Party Certifier’s certification process requires the Third Party Certifier to
examine an Applicant’s request for WOSB or EDWOSB certification based on the requirements
set forth in 13 C.F.R. part 127 and will only approve an Applicant’s request if the Applicant has
satisfied all such requirements.
Yes

No

The proposed Third Party Certifier’s certification process requires the Applicant to submit
information demonstrating, in accordance with 13 C.F.R. part 127, whether the concern is:
a. A small business concern under SBA’s size standards for its primary industry
classification;
b. At least 51 percent owned and controlled by one or more women who are
United States citizens; and
c. In the case of a concern applying for EDWOSB certification, at least 51
percent owned and controlled by one or more women who are United States
citizens and economically disadvantaged.
Yes

No

The proposed Third Party Certifier’s certification process requires, at a minimum, that each
Applicant submit a copy of the following documents (signed, as applicable):
a. Birth certificates, naturalization papers, or unexpired passports for owners
who are women;
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b. Copy of the joint venture agreement with any third party, if applicable;
c. For limited liability companies: (i) Articles of organization (also referred to as
certificate of organization or articles of formation) and any amendments; and
(ii) Operating or member agreement, and any amendments;
d. For corporations: (i) Articles of incorporation and any amendments; (ii) Bylaws and any amendments; (iii) All issued stock certificates, including the
front and back copies, signed in accord with the by-laws; (iv) Stock ledger;
and (v) Shareholder or voting agreements, if any;
e. For partnerships, the partnership agreement and any amendments;
f. For sole proprietorships (and corporations, limited liability companies and
partnerships if applicable), the assumed/fictitious name certificate(s);
g. Information to verify the business is small for its primary NAICS (see 13
C.F.R. part 121); AND
h. For EDWOSBs, in addition to the above, SBA Form 413, Personal Financial
Statement, available to the public at https://www.sba.gov/document/sbaform-413-personal-financial-statement-8a-business-development-program
for each woman claiming economic disadvantage; the three most recent
personal income tax returns (including all schedules and W-2 forms) for the
women claiming economic disadvantage and their spouses, unless the
individual and their spouse are legally separated.
Yes

No

The proposed Third Party Certifier’s certification process requires the Applicant to have a
profile on System for Award Management (SAM) at https://www.sam.gov/SAM/.
Yes

No

The proposed Third Party Certifier’s certification process requires the Third Party Certifier to
notify the Applicant that is must represent its status on SBA’s website at
http://certify.sba.gov/after registering in SAM and submitting the required document in
http://certify.sba.gov/
Yes

No

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The proposed Third Party Certifier’s certification process requires the Third Party Certifier to
maintain the right, in its discretion, to request clarification of information contained in the
WOSB or EDWOSB application at any time in the certification process.
Yes

No

The proposed Third Party Certifier’s certification process requires the Third Party Certifier to
ensure that all certified WOSBs and EDWOSBs meet the eligibility criteria of the program even
if there are any subsequent changes in statute or regulations.
Yes

No

The proposed Third Party Certifier’s certification process requires the Applicant to promptly
inform the Third Party Certifier of any changed circumstances that could adversely affect the
Applicant’s eligibility for the program (including a change in the WOSB or EDWOSB, as well
as a change in SBA regulation) and requires the Third Party Certifier to consider any changed
circumstances for an Applicant occurring subsequent to application and which adversely affect
eligibility. The certification process must show that the Third Party Certifier will consider
whether such changed circumstances are grounds to decline the Applicant’s application.
Yes

No

The proposed Third Party Certifier’s certification process requires the decision to approve or
decline WOSB or EDWOSB certification to be in writing and state the specific reasons for
decline.
Yes

No

The proposed Third Party Certifier’s certification process requires decline of an application for
WOSB or EDWOSB Certification if:
a. There are any deficiencies from one or more certification criteria identified in
13 C.F.R. part 127, and the Applicant fails to address the deficiencies in a
timely and acceptable manner.
b. The Applicant unduly delays, limits, or denies the Third Party Certifier access
to the establishment, products, or records needed to verify compliance with
certification criteria.

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c.
d. The Third Party Certifier discovers that the Applicant, or any of its officers or
employees, engages in any improper actions in connection with the
certification process, such as providing false information to the Third Party
Certifier or SBA.
e. The Applicant is currently debarred or suspended from Federal Government
Contracting.
Yes

No

The proposed Third Party Certifier’s certification process requires the Third Party Certifier to
maintain a written quality assurance program identifying the review/audit process, its
documentation, methods of internal review, identification of staff position(s) performing the
reviews, and at least annual reviews. Attached is the written quality assurance program.
Yes

No

Attached is a sample WOSB certification. All of the proposed Third Party Certifier’s WOSB
certifications will meet the following requirements:
a. Will be based on circumstances existing on the date of application or any
subsequent certification (i.e. a re-certification) and identify such date on the
certification
b. Will state on the certification that “This WOSB Certification will be effective
for three years from the date identified on the certification letter. The
identified small business must attest annually to meeting the WOSB or
EDWOSB eligibility requirements. If there is a change in SBA’s regulations
that makes the WOSB or EDWOSB ineligible or if there is a change in the
WOSB or EDWOSB that makes the WOSB or EDWOSB ineligible, this
WOSB or EDWOSB Certification is immediately invalid. ”
c. Will require the WOSB or EDWOSB to promptly inform the Third Party
Certifier and SBA of any changed circumstances, including a change in
SBA’s regulation or a change in the WOSB or EDWOSB, that could make the
WOSB or EDWOSB ineligible for the WOSB program or of any intended
changes that may affect certification in the future. The certification process
must show that the Third Party Certifier will consider whether such changed
circumstances are grounds for withdrawal.
d. Will provide that failure to inform the Third Party Certifier of any such
changed circumstances constitutes good cause for which the certification may
be withdrawn or grounds for decline of the application for certification.
e. Will be dated and state that: “The identified small business is an eligible

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WOSB or EDWOSB for the WOSB Program, as set forth in 13 C.F.R. part
127 and has been certified as such by an SBA approved Third Party Certifier
pursuant to the Third Party Certifier Agreement, dated
, and available
at www.sba.gov/wosb.”
f. Will state that “The WOSB or EDWOSB must not misrepresent its
certification status to any other party, including any local or State government
or contracting official or the Federal government or any of its contracting
officials.”
Yes

No

Withdrawal of Certification
The proposed Third Party Certifier’s certification process requires the Third Party Certifier to
immediately withdraw a WOSB or EDWOSB certification if:
a. The WOSB or EDWOSB no longer satisfies any of the requirements in 13
C.F.R. part 127 of SBA’s regulations.
b. The WOSB or EDWOSB unduly delays, limits, or denies the Third Party
Certifier access to the establishment, products, or records needed to verify
compliance with the certification criteria.
c. The WOSB or EDWOSB, or any of its officers or employees, engages in any
improper actions in connection with the certification process, such as
providing false information to the Third Party Certifier or SBA.
Yes

No

The proposed Third Party Certifier’s certification process requires the WOSB or EDWOSB to
promptly notify the Third Party Certifier in writing of any new conditions that could cause the
WOSB or EDWOSB to no longer satisfy the requirements set forth in 13 C.F.R. part 127 or of
any intended changes to that may affect certification in the future.
Yes

No

The proposed Third Party Certifier’s certification process requires the Third Party Certifier to
immediately notify SBA in writing if any certification has been withdrawn, as well as the basis
for withdrawal.
Yes

No

The proposed Third Party Certifier’s certification process requires the withdrawal letter to the
certified WOSB or EDWOSB to explain the following:
a. The business concern is withdrawn as a certified WOSB or EDWOSB under
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the WOSB Program, effective on the date stated.
b. The business concern will not submit an offer on or receive award of any
WOSB or EDWOSB contract under the WOSB Program starting from the
date of the withdrawal;
c. The business concern will no longer be represented as a WOSB or EDWOSB
in the System for Award Management (SAM);
d. The business concern is obligated by contract to complete all previously
awarded WOSB or EDWOSB contracts, including modifications within the
scope and price options which may be exercised.
Yes

No

Supporting Documentation
The proposed Third Party Certifier has a written policy of documentation management and
retention evidencing the requirements below. Attached is such policy.
Yes
No
The proposed Third Party Certifier has the capacity to and will retain all of the documentation
submitted by the certified WOSB or EDWOSB to the Third Party Certifier for a period of six (6)
years from the date of initial certification, as well as any recertification. The proposed Third
Party Certifier will maintain such documents in a permanent and secure system and will not
allow Applicants (either before or after their applications are considered) to withdraw or modify
supporting documents once submitted (but will allow additional documents to be submitted if the
Applicant indicates that modifications were made in already-submitted supporting documents).
Yes

No

The proposed Third Party Certifier has a written policy addressing how it will handle WOSB and
EDWOSB applications, documents, and any other materials received from the WOSB or
EDWOSB as part of the certification process if the approved Third Party Certifier no longer
processes applications, including the prompt manner by which it will deliver all such
applications, documents and any other materials to the SBA and the efforts it will make to effect
an orderly and efficient delivery to SBA. The written policy is attached.
Yes

No

The proposed Third Party Certifier has a mechanism for obtaining and will obtain authority from
the Applicant and the certified WOSB or EDWOSB to provide SBA or any Federal Government
entity (e.g., the U.S. Government Accountability Office) with any documentation relied upon for
certification upon request by SBA or any Federal Government entity in response to a status
protest, eligibility examination, performance review, investigation or audit in the timeframe
specified.
Yes

No
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The proposed Third Party Certifier has the following information available for review by SBA or
any Federal Government entity (e.g., the U.S. Government Accountability Office) and will
provide such information to SBA at any time requested after becoming an approved Third Party
Certifier in the timeframe specified:
a. Application screening and processing procedures
b. Application documents and analyses
c. All correspondence between the Applicant and the Third Party Certifier.
Yes

No

SBA Oversight
The proposed Third Party Certifier agrees to be subject to a performance review by SBA or any
other Federal agency at any time, including, but not limited to, a full performance review every
three years.
Yes

No

The proposed Third Party Certifier agrees to supply, in a timely manner, all requested
information, files and documents to SBA or any other Federal agency in the timeframe specified
for any evaluation or review of the Third Party Certifier and its process or compliance with this
Agreement; and also for the evaluation of any certified concern. The SBA or any other Federal
agency has the right to review all requested information in any and all formats available,
including electronic and hard copy. The SBA or any other Federal agency has the right to enter
any facility in which such requested information, files and documents are kept and review such
materials.
Yes

No

The proposed Third Party Certifier agrees to immediately notify SBA of any change to its status
in its certification requirements or documents submitted herein, as well as any change to any
answer provided herein, that could cause the Third Party Certifier to no longer satisfy any of the
requirements of this Certification.
Yes

No

10

The proposed Third Party Certifier agrees to provide SBA with a report on January 2nd of each
year, or if that day falls on the weekend or a Federal Government holiday, then on the business
day thereafter, stating that there have not been any changes to any of the answers provided in this
Certification Form or the documentation provided thereto that could cause the Third Party
Certifier to no longer satisfy the requirements of identified herein.
Yes

No

The proposed Third Party Certifier agrees SBA reserves the right to amend the requirements for
the WOSB Program at any time. Revisions to the requirements may require termination of
approval as a Third Party Certifier, modification of this Certification Form, re-approval of the
Third Party Certifier and/or re-certification of existing certified WOSBs or EDWOSBs.
Yes

No

The proposed Third Party Certifier agrees that it if it is uncertain about any requirement under 13
C.F.R. part 127, or SBA’s interpretation of any requirement therein, it is the responsibility of the
Third Party Certifier to seek clarification from SBA. In the event of any conflict between SBA’s
interpretation of its regulations and those of any the Third Party Certifier, SBA’s interpretation
shall control.
Yes

No

The proposed Third Party Certifier agrees, upon certification, to indemnify, defend and hold
SBA, its officers, directors, agents, employees and other related parties harmless from and
against any and all liabilities, damages, losses, expenses, claims, demands, suits, fines, or
judgments that include reasonable attorneys' fees, costs and expenses, incidental thereto, which
may be suffered by, accrued against, charges to or recoverable from any person or entity, by
reason of any claim arising out of or relating to any act or error or omission, or misconduct of the
Third Party Certifier, its officers, directors, agents, employees or subcontractors.
Yes

No

The proposed Third Party Certifier agrees that the SBA has the authority under 13 C.F.R. part
127 to conduct program examinations and protests on concerns that that have been approved by
the Third Party Certifier and that SBA may find that these business concerns are not eligible.
Yes

No

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The proposed Third Party Certifier agrees that it is an independent contractor and not an Agent
as defined in 13 C.F.R. § 103.1; however, it agrees to comply with the procedures set forth in
13 C.F.R. part 103 with respect to any proposed suspension and revocation of the Third Party
Certifier’s ability to accept, review, and examine applications for WOSB or EDWOSB
certification, as well as to decline and withdraw WOSB and EDWOSB certifications.
Yes

No

The proposed Third Party Certifier agrees that, in addition to suspension and revocation pursuant
to 13 C.F.R. part 103, SBA may terminate The Third Party Certifier Agreement, thereby
terminating the Third Party Certifier’s authority to approve applications, for any of the reasons
identified below:
a. The Third Party Certifier fails to observe, perform, or fulfill any of the terms
of this Agreement or its duties hereunder;
b. The Third Party Certifier becomes insolvent;
c. The Third Party Certifier’s certification process does not comply with SBAapproved certification standards or is not based on the same EDWOSB or
WOSB eligibility requirements as set forth in 13 C.F.R. part 127, as either of
the foregoing may exist from time to time;
d. Through one or more performance reviews of the Third Party Certifier, the
SBA determines that the Third Party Certifier did not properly certify one or
more WOSBs or EDWOSBs or failed to withdraw certification from one or
more WOSBs or EDWOSBs; or
e. Any other reason that SBA finds constitutes good cause for termination of this
Agreement.
Yes

No

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All the statements and information provided in this form and any documents submitted are
true, accurate and complete. If assistance was obtained in completing this form and the
supporting documentation, I have personally reviewed the information and it is true and
accurate. I understand that these statements are made for the purpose of determining
eligibility as a Third Party Certifier under the WOSB Program.
I am an officer of the proposed Third Party Certifier authorized to represent it, to sign this
certification on its behalf, and lawfully to bind it to all of the obligations set forth herein.
Warning: By signing this certification you are representing on your own behalf, and on
behalf of the Third Party Certifier, that the information provided in this certification, and
any document or supplemental information submitted, is true and correct as of the date set
forth opposite your signature. Any intentional or negligent misrepresentation of the
information contained in this certification may result in criminal, civil or administrative
sanctions including, but not limited to: 1) fines of up to $500,000, and imprisonment of up
to 10 years, or both, as set forth in 15 U.S.C. § 645 and 18 U.S.C. § 1001, as well as any
other applicable criminal laws; 2) treble damages and civil penalties under the False
Claims Act; 3) double damages and civil penalties under the Program Fraud Civil
Remedies Act; 4) suspension and/or debarment from all Federal procurement and
nonprocurement transactions; and 5) termination or denial as an SBA approved Third
Party Certifier.
Signature

Date _ /_ /_

Print Name (First, Middle, Last)
Title
National Certifying Entity Name

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