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Owner Title Sheet Template - Commonwealth Of Virginia Department Of Small Business And Supplier Diversity

COMMONWEALTH OF VIRGINIA

Department of Small Business and Supplier Diversity

SWaM and Micro Business Certification Program

Owner Title Sheet

• Company Name:

• SWaM Certification / Record Tracking number:

Do you also want to apply for “Micro Business” Certification? Yes____, No_____

Name of Owner (s)

Title/Position in the company

Ownership

• Does anyone from the list above have more than 10% of ownership of another firm(s)?

Yes

, No

If Yes, Firm Name:

Person’s name:

Explain the Business Relationship:

If you have 10% of ownership of another firm(s), please submit the following

documents for each firm:

1. Federal Tax Return – complete return from the most recent year and 1

page of

previous two years

2. Federal Form 941(Employer’s Quarterly Federal Tax Return) - 1

page only from

the most recent four quarters if you are qualifying under the number of employees

for small business status

I attest that the information provided herein is true and accurate to the best of my

knowledge. I understand that any information willfully falsified or intentionally omitted

may result in the firm being de-certified and/or disbarred from bidding on State contracts

for a period of up to two years and prosecuted under Commonwealth of Virginia fraud

statutes.

Business Owner’s Signature: ______________________________

Date: ________________________________

Revised 1/13/2015

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Owner Title Sheet Template - Commonwealth Of Virginia Department Of Small Business And Supplier Diversity