0524-NEW SBIR STTR Funding Form Majority Owned

OMB Number 0524-XXXX;
Expiration XX/XX/XXXX
Certification for SBIR Applicants that are Majority-Owned by Multiple Venture
Capital Operating Companies, Hedge Fund or Private Equity Firms
The agency must require any SBC that is majority-owned by multiple venture capital operating
companies, hedge funds, or private equity firms to submit the following certification with its SBIR
applications.
Any small business that is majority-owned by multiple venture operating companies (VCOCs), hedge
funds, or private equity firms and is submitting an application for an SBIR Funding Agreement must
complete this certification prior to submitting an application. This includes checking all of the boxes
and having an authorized officer of the Applicant sign and date the certification each time it is requested.
Please read carefully the following certification statements. The Federal Government relies on the
information to determine whether the business is eligible for a Small Business Innovation Research
(SBIR) program award and meets the specific program requirements during the life of the Funding
Agreement. The definitions for terms used in this certification are set forth in the Small Business Act,
SBA regulations (13 CFR part 121), the SBIR/STTR Policy Directive and also any statutory and
regulatory provisions referenced in those authorities.
If the Funding Agreement officer believes that the business may not meet certain eligibility requirements
at the time of award, he/she is required to file a size protest with the U.S. Small Business Administration
(SBA), which will determine eligibility. At that time, SBA will request further clarification and
supporting documentation in order to assist in the verification of any of the information provided as part
of a protest. If the Funding Agreement officer believes, after award, that the business is not meeting
certain Funding Agreement requirements, the agency may request further clarification and supporting
documentation in order to assist in the verification of any of the information provided.
Even if correct information has been included in other materials submitted to the Federal Government,
any action taken with respect to this certification does not affect the Government’s right to pursue
criminal, civil or administrative remedies for incorrect or incomplete information given in the
certification. Each person signing this certification may be prosecuted if they have provided false
information.
The undersigned has reviewed, verified, and certifies that (all boxes must be checked):
(1)
firm.

The Applicant is NOT more than 50% owned by a single VCOC, hedge fund, or private equity

(2)
The Applicant is more than 50% owned by multiple domestic business concerns that are
VCOCs, hedge funds, or private equity firms.
(3)
I have registered with SBA at www.SBIR.gov as a business that is majority-owned by multiple
VCOCs, hedge funds or private equity firms.
(4)
I understand that the information submitted may be given to Federal, State, and local agencies
for determining violations of law and other purposes.

OMB Number 0524-XXXX;
Expiration XX/XX/XXXX
(5)
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,
in general, these statements are made for the purpose of determining eligibility for an SBIR Funding
Agreement and continuing eligibility.
I understand that the certifications in this document are continuing in nature. Each SBIR
(6)
Funding Agreement for which the small business submits an offer or application or receives an award
constitutes a restatement and reaffirmation of these certifications.
(7)
I understand that I may not misrepresent status as small business to: 1) obtain a contract under
the Act; or 2) obtain any benefit under a provision of Federal law that references the SBIR program.
(8)
I am an officer of the business concern authorized to represent it and sign this certification on
its behalf. By signing this certification, I am representing on my own behalf, and on behalf of the SBIR
Applicant or Awardee, that the information provided in this certification, the application, and all other
information submitted in connection with this application, is true and correct as of the date of
submission. I acknowledge that 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, restitution and/or imprisonment under 18 U.S.C. 1001; (2) treble damages and civil
penalties under the False Claims Act (31 U.S.C. 3729 et seq.); (3) double damages and civil penalties
under the Program Fraud Civil Remedies Act (31 U.S.C. 3801 et seq.); (4) civil recovery of award
funds, (5) suspension and/or debarment from all Federal procurement and non-procurement transactions
(FAR subpart 9.4 or 2 CFR part 180); and (6) other administrative penalties including termination of
SBIR/STTR awards.
Signature:

Date:

Print Name (First, Middle, Last):
Title:
Business Name:

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searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
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64131, Attention Policy Section. Do not return the completed form to this address. National Institute of Food and Agriculture US
Department of Agriculture OMB No. 0524-NEW Form Approved For Use Through xx/xx/xxxx