American Indian Tribe Information

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Approval No. OMB 3245-0331
Expiration Date: 04/30/2017
American Indian Tribe Information
The American Indian Tribe that owns at least 51 percent of the applicant business
concern
must complete this form. 13 C.F.R. § 124.109(b).
YOUR SIGNATURE ON THIS FORM INDICATES THAT YOU FULLY UNDERSTAND
ALL QUESTIONS AND CERTIFIES THAT ALL RESPONSES AND DOCUMENTS
ARE TRUTHFUL AND ACCURATE.
Name of Applicant Business Concern (include any trade or d.b.a. names):
_________________________________________________________________________
Name of American Indian Tribe (AIT): _________________________________________
Note: AIT means any Indian tribe, band, nation, or other organized group or community of
Indians, which is recognized as eligible for the special programs and services provided by the
United States to Indians because of their status as Indians, or is recognized as such by the State
in which the tribe, band, nation, group, or community resides. 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: ______________
Indian Tribe percent ownership of applicant business concern: ___________
Please answer the following questions and provide the required documents:
1. Has the Tribe previously established its economic disadvantaged status
[ ]Yes
[ ]No
under the 8(a) BD Program? If yes, provide a copy of the SBA
determination. If no, provide the following information for the tribe:
•
The number of tribal members.
•
The present tribal unemployment rate.
•
The per capita income of tribal members, excluding judgment

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