Form Ioci 14-4 - Recognition Certification Affidavit - Business Enterprise Program Page 3
Download a blank fillable Form Ioci 14-4 - Recognition Certification Affidavit - Business Enterprise Program in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Ioci 14-4 - Recognition Certification Affidavit - Business Enterprise Program with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3State of Illinois
Department of Central Management Services
BUSINESS ENTERPRISE PROGRAM
RECOGNITION CERTIFICATION AFFIDAVIT
8. Do you have any ownership in any other firms:
Yes
No
If Yes, complete the chart below: Submit most recent Federal Income tax returns; include all attachments and schedules for
any affiliate.
Name of Affiliate
Address
Date Established
Gross Sales
9. List all the names of the owners of the affiliate firm(s). Complete the chart below.
Ethnic
Date of
Owner Name
Title/Position
Gender
% of Ownership
Group
Ownership
10. Submit most recent Federal Income tax returns; include all schedules and attachments for any affiliate firm(s).
11. Pursuant to the requirements of Illinois Administrative Code, Title 44, Section 10.90, I understand that I must notify CMS within thirty (30)
days of any change affecting my firm’s ability to meet BEP program eligibility requirements.
12. I/We understand and acknowledge that to fraudulently obtain or retain certification or public monies, to willfully make a false statement to
an official for the purpose of influencing certification eligibility or to obstruct or impede an official or employee who is investing the qualifications
of a business which has requested certification is a Class 2 felony subject to prosecution under Chapter 38, Article 33C of the Criminal Code
of the State of Illinois.
13. I/We affirm that the Disabled, Minority or Female interest in the business constitute the majority control over business operations. Further,
the undersigned agrees to provide written changes in the submitted information after the filling of this application and before the work of
this firm is completed on any agency awarded contract. The agency must be informed in writing of the change, and failure to do so may
result in decertification or denial of certification. The firm must further provide, upon request, information of any work performed on any
specified project regarding type of work performed, its duration, amount of payment to the firm, and to permit the audit and examination of
books, records and files of the named firm.
14. ANY MATERIAL MISREPRESENTATION OF INFORMATION IN THIS DOCUMENT WILL BE GROUNDS FOR: (1) DENIAL OF CERTIFI-
CATION (2) DECERTIFICATION (3) DEBARMENT (4) TERMINATING ANY CONTRACT(s) THAT MAY BE AWARDED AND (5) INITIATING
ACTION UNDER FEDERAL AND/OR STATE LAWS CONCERNING FALSE STATEMENTS.
________________________________________________________________________________________________________________________
Print Name
Print Title
Signature Of Owner
Date
________________________________________________________________________________________________________________________
Print Name
Print Title
Signature Of Owner
Date
________________________________________________________________________________________________________________________
Print Name
Print Title
Signature Of Owner
Date
________________________________________________________________________________________________________________________
Print Name
Print Title
Signature Of Owner
Date
17. Notary Seal: Subscribed and sworn to before me this ______ day of ______________________, 20___.
Signed: ________________________________________ Notary Public in and for the County of: ________________________ State: ____
My commission expires: __________________________
This affidavit and supporting documentation should be delivered to the Illinois Department of Central Management Services,
Business Enterprise Program, 100 West Randolph Suite 4-100, Chicago Illinois 60601.
Page 3
IOCI 14-4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal