Form 3 Form 3 NPA Annual AbilityOne Representations and Certifications

NPA Annual AbilityOne Representations and
Certifications (ARC)
Federal Fiscal Year:
Agency Name:
Employer Identification Number:
Mailing Address: [Enter text]
Phone Number:
Name and email address of principal officer:

[Enter text]
[Enter text]
[Enter text]
[Enter number]
[Enter text]

Part I: Summary
ABILITYONE Revenue
ABILITYONE Subcontracted
ABILITYONE Number of Participating Employees Cumulative
ABILITYONE Hours Worked by Participating Employees
ABILITYONE DLH Ratio

[AutoFill]
[AutoFill]
[AutoFill]
[AutoFill]
[AutoFill]

NPA ODLH Ratio

[AutoFill]

Part II Signature Block
Under penalty of perjury, I declare that I have examined this return, including accompanying
schedules and statements, and to the best of my knowledge and belief, it is true, correct, and
complete. 18 U.S.C. § 1621 and 28 U.S.C. § 1746.
Signature of NPA’s Principal Officer [Signature]

Date

[Date]

Declaration of the preparer (other than Principal Officer): I have prepared this return, and it is
based on all information of which I have knowledge.
Preparer Information
Preparer’s name
[Open text]
Preparer’s email address and phone number
[Open text]
Preparer’s Signature
[Signature]
Date [Date]
Firm Information (if applicable)
Name of Firm and EIN
[Open text]
Firm’s mailing address, email address and phone number [Open text]

Part III. NPA AbilityOne Program Information
1. ABILITYONE REVENUE
Procurement List Items
1.1 NPA Revenue from AbilityOne Products
1.2 NPA Revenue from AbilityOne Services
1.3 NPA Revenue from Military Resale (Direct & Warehouse)
Total AbilityOne Revenue
Base Supply Centers
1.4 NPA Revenue from AbilityOne products
1.5 Base Supply Centers Total Revenue

$ [Number]
$ [Number]
$ [Number]
$ Auto Calculation
$ [Number]
$ [Number]

2. Total Number of Participating Employees Whose Eligibility was Derived From a
Government or Private Source (Select all that apply and enter value)
☐ Medicaid

[Enter number]

☐ Social Security

[Enter number]

☐ Veterans Benefits Administration

[Enter number]

☐ Vocational Rehabilitation Services

[Enter number]

☐ Individualized Education Program/504 plan/Services plan
☐ Other State and/or Local Disability Services

[Enter number]
[Enter number]

☐ Private Licensed Professional

[Enter number]

3. EMPLOYMENT

ABILITYONE EMPLOYMENT
3.1 Number of Participating Employees
3.2 Number of Non-Participating Employees
performing DLH
3.3 Number of employees who self-identify as a
person with a disability performing indirect labor

[Number]

[Number]

Total
employed
during the
year
[Number]

[Number]

[Number]

[Number]

[Number]

[Number]

[Number]

On Oct 1

On Sep 30

4. Direct Labor Hours (DLH) (Hours should include overtime, vacation, holiday, sick leave)
ABILITYONE DIRECT LABOR HOURS

PRODUCTS

SERVICES

4.1 Participating Employee direct labor hours

[Number]

[Number]

4.2 Direct labor hours performed by NonParticipating Employees

[Number]

[Number]

Auto
Calculation

Auto
Calculation

4.3 Total direct labor hours (4.1 + 4.2)
4.4 Percentage of direct labor hours performed
by Participating Employees

Auto
Auto
Calculation % Calculation %

TOTAL
Auto
Calculation
Auto
Calculation
Auto
Calculation
Auto
Calculation
%

5. Wages for Employees (Wages include overtime, vacation, holiday, sick leave, and fringe
payments)
ABILITYONE WAGES
5.1 Wages paid to Participating Employees
5.2 Wages paid to DLH Non-Participating
Employees
5.3 Lowest hourly wage paid to Participating
Employees
5.4 Highest hourly wage paid to Participating
Employees
5.5 Mean hourly wage paid to Participating
Employees

PRODUCTS
$ [Number]

SERVICES
$ [Number]

TOTAL
$ Auto Calc

$ [Number]

$ [Number]

$ Auto Calc

$ [Number]

$ [Number]

N/A

$ [Number]

$ [Number]

N/A

$ Auto
Calculation

$ Auto
Calculation

$ Auto
Calculation

6. Select other employment benefits offered to Participating Employees (Select all that
apply)
☐ NPA-sponsored Health Insurance
☐ Vacation/Sick/PTO Leave
☐ Retirement plan

☐ Short-term disability

☐ Workers’ compensation

☐ Unemployment compensation

☐ Tuition assistance or other education support
☐ Other

Optional: Benefits narrative may be provided here:

[Enter description]

[Open text]

7. Participating Employee Career Mobility
7.1

Report Participating Employee mobility outcomes within the NPA.
☐ Lateral Movement (Labor position change utilizing different skills but not a
[Enter number]
promotion)
☐ Upward Movement (Promotion or labor position change resulting in increased wages
or benefits)
☐ Not Supervisory

☐ Supervisory

[Enter number]
[Enter number]

☐ Demotion (Labor position change resulting in decreased wages or benefits)
[Enter number]
☐ No Movement

[Enter number]

For Employees with No Movement:
☐ Employee stated desire to remain in present position.

[Enter number]

☐ Unknown

[Enter number]

☐ Employee expressed concern regarding potential government benefit disqualification
as a result of increased wages.
[Enter number]

7.2 Report Participating Employee mobility outcomes outside the NPA.
☐ New employment by Federal/State/Local government
☐ New employment by Federal/State/Local contractor
☐ New employment by For-Profit/Non-Profit Employer
☐ Unknown Employer Type

[Enter number]
[Enter number]
[Enter number]
[Enter number]

8. Subcontracting: NPA as Prime Contractor for Procurement List work

8.1 Is any part of the NPA’s Procurement List project(s) subcontracted? [Y/N Choice (If Y, then
complete 8.2-8.6. If N, then skip to 9.)]
8.2 Total value of Procurement List project(s) subcontracted to AbilityOne NPA(s):
$ [Enter number]
8.3 Total value of Procurement List project(s) subcontracted to Small Business Entities:
$ [Enter number]
8.4 Total value of Procurement List project(s) subcontracted to Other Than Small Business
Entities (includes Non-AbilityOne Nonprofit Organizations and Large Businesses:
$ [Enter number]
8.5 Type of Subcontracting Products/Services Purchased

[Open text.]

8.6 Non-AbilityOne Subcontractor Category (Select all that apply)
☐ Large Business/Commercial Entities
☐ Nonprofit Organization
☐ SBA - 8(a) Program

☐ SBA - Women-Owned

☐ SBA - Veteran-Owned and/or Service-Disabled Veteran-Owned

☐ SBA - Minority Owned

Part IV Total NPA Information

1. TOTAL NPA EMPLOYMENT
1.1 Number of Qualifying Direct Labor Employees
1.2 Number of employees without qualifying
disabilities performing DLH

[Number]

[Number]

Total
employed
during the
year
[Number]

[Number]

[Number]

[Number]

On Oct 1

On Sep
30

2. NPA OVERALL DIRECT LABOR HOURS
2.1 Direct labor hours of Qualifying Direct Labor
Employees
2.2 Direct labor hours of Non-Qualifying Direct Labor
Employees
2.3 Total direct labor hours (2.1+1.2)
2.4 Percentage of Qualifying Direct Labor Employees
direct labor hours
3. VETERANS EMPLOYMENT
3.1 Veterans employed on a Procurement List project
3.2 Veterans employed by the NPA
3.3 Total veteran wages

PRODUCTS

SERVICES

[Number]

[Number]

[Number]

[Number]

Auto
Calculation

Auto
Calculation
Auto
Calculation
%

Auto
Calculation %

TOTAL
Auto
Calculation
Auto
Calculation
Auto
Calculation
Auto
Calculation
%

[Number]
[Number]
$ [Number]

Part V Other NPA Questions
1. If applicable, did the NPA submit the IRS Form 990 to the IRS within the last year?
[Y/N/NA]
o If Y, provide a copy.
[Link to 990 file upload process]
o If N, provide explanation.
[Open text]
2. Did the NPA receive an independent financial audit report for the last year? NOTE: This
can be calendar or fiscal year, depending on the NPA's financial closing period.
[Y/N/NA]
o If Y, provide copy of the auditor’s summary report. [Link to auditor summary
report upload process]
o If N, provide explanation.
[Open text]
3. How many members are on the NPA’s Board?

[Drop down for number]

4. How many NPA board members voluntarily self-identify as a person with a disability?
[ Drop down for number]
5. How many of your Procurement List contract sites are represented by a union/unions?
[Enter number]
6. How many NPA participating employees are members of a union?
[Enter number]

7. Has the NPA received had any of the following supports from its designated CNA over
the past year? (Select all that apply):
☐ Technical assistance or training
☐ Support on direct business development (other than through participation in the
CNA’s opportunity notice process)
☐ Financial support
☐ Other - Describe
[Open text]