SBA Form 1010-CDC Community DEVELOPMENT Corporation Information

OMB Approval No. 3245-0331

_{Expiration Date: 04/30/2017}

Community Development Corporation Information

The Community Development Corporation that owns the applicant business concern must complete this form. 13 C.F.R. § 124.111.

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 Parent Community Development Center (CDC): _________________________________________

Note: A CDC means a nonprofit organization responsible to residents of the area it serves which has received financial assistance under 42 U.S.C. 9805, 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: ______________}

CDC percent ownership of applicant: ___________

_{Please answer the following questions and provide the required documents:}

1. Does the CDC or subsidiary of the CDC own 50% or more of another business 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
2. Does the CDC own the applicant concern directly (rather than through a subsidiary)?	[ ]Yes	[ ]No
3. Does the CDC own the applicant business concern through a subsidiary? If yes, provide the name and address of that subsidiary.	[ ]Yes	[ ]No

Please provide the following documents:

 Documentation which demonstrates the legal status of the CDC.

 Documentation showing the CDC’s ownership of the applicant business concern.

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 the 8(a) BD Program.

_{Form must be signed by the CDC’s President or CEO.}

_{___________________________}

_{________________________}

_{__________________}

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-CDC (3/11)

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