Form 1 Form

NIH & CDC Small Business Innovation Research Program
Certification for Applicants That Are Majority-Owned by Multiple Venture Capital Operating
Companies, Hedge Fund, or Private Equity Firms
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705
Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0001). Do not return the completed form to this
address.

Any small businesses that are majority-owned by multiple venture operating companies (VCOCs), hedge funds
or private equity firms and are 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 organization 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 the terms
used in this certification are set forth in the Small Business Act, SBA regulations (13 C.F.R. Part 121), the SBIR
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, they are required to file a size protest with the U.S. Small Business Administration (SBA), who
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. The applicant is NOT more than 50% owned by a single VCOC, hedge fund or private equity firm.
Yes

No

2. The applicant is more than 50% owned by multiple domestic business concerns that are VCOCs,
hedge funds, or private equity firms.
Yes

No

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.
Yes

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SBIR Application VCOC Certification

I understand that the information submitted may be given to Federal, State and local agencies for
determining violations of law and other purposes.
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 funding
agreement for which the small business submits an offer or application or receives an award constitutes a
restatement and reaffirmation of these certifications.
I understand that I may not misrepresent status as small business to: 1) obtain a contract under the Small
Business Act; or 2) obtain any benefit under a provision of Federal law that references the SBIR Program.
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 nonprocurement transactions (FAR
Subpart 9.4 or 2 C.F.R. part 180); and
(6) other administrative penalties including termination of SBIR/STTR awards.

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SBIR Application VCOC Certification

My signature is verification that the statements checked () above are true and complete. I am aware that any
false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties.

Date
Signature
Printed Name (First, Middle, Last)
Title
Organization Name

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SBIR Application VCOC Certification