Va Form 0877 - Vetbiz Vendor Information Pages Verification Program

Form Approved, OMB No. 2900-0675

Respondent Burden: 5 Minutes

VETBIZ VENDOR INFORMATION PAGES VERIFICATION PROGRAM

INSTRUCTIONS:

Each business owner/stockholder must provide % of business ownership, identify veteran status (yes/no), sign and date the form. Owners/stockholders who are veterans,

service-disabled veterans or eligible surviving spouses must also provide SSN or VA Claim number and must check the appropriate block under Veteran Status. Ownership must total 99-100%. VA

does not intend to collect SSN data from non-veterans. If this data is submitted, VA will destroy the record within 30 days. After completion, print a copy for your records, fax to (202) 303-3330 or

electronically submit the form to VA. DO NOT MAIL OR EMAIL the form.

PART I - CONSENT TO ACCESS AND VERIFY VETERAN(S) OWNER(S)/VETERAN(S) STOCKHOLDER(S) RECORD(S)

Each veteran owner/veteran stockholder named herein authorizes consent for the Center for Veterans Enterprise (CVE) personnel to access and verify their records. CVE will match your information with records maintained by VA's

Beneficiary Identification Records Locator Subsystem database. Please see for definitions of veteran, service-disabled veteran, owner, stockholder, Veteran-Owned Small Business (VOSB),

Service-Disabled Veteran-Owned Small Business (SDVOSB), and eligible surviving spouse.

NAME OF COMPANY

DUNS

DBA

Colorado Engineering, Manufacturing, and

CEM-Tek, Inc.

079330712

Technology, Inc.

VETERAN STATUS

SSN/VA FILE NO./

NAME(S) OF EACH

CLAIM NO. FOR

SIGNATURE OF EACH

DATE

DATE

BUSINESS OWNER/STOCKHOLDER/

% OF

VETERAN(S) &

SIGNED

OF BIRTH

BUSINESS OWNER(S)

SURVIVING SPOUSE

OWNER-

SURVIVING

(Mr./Ms., First Name, Middle, Last, Jr./Sr./III)

SHIP

SPOUSE ONLY

(Skip if Non-Veteran)

Stan VanderWerf

100

149-54-8518

3/3/1961

X

4/30/2014

PART II - AFFIRMATION

By electronically signing or FAXing this signed form to (202) 303-3330, and I affirm that the articles of incorporation (or other legal documents establishing the business) are

filed with my state and such articles established that at least 51% of the business is owned by veterans or service-disabled veterans, or eligible surviving spouses, as required

by 38 U.S. Code Section 8127 (l) (2) and 38 Code of Federal Regulations Part 74. I affirm that each of the owners of the business (or in the case of a business with stock,

each of the stockholders) is eligible to participate in Federal contracting and that neither the business nor any of the individual owners appears on the Excluded Parties List at

as identified in Federal Acquisition Regulation 9.404-3. I further affirm that I have read and understand the language in 38 Code of Federal Regulations Part 74 and that the

business is controlled by individuals eligible to participate in the VOSB or SDVOSB verification program. A false statement on any part of your application may be punished

by fine or imprisonment (U.S. Code title 18, section 1001). I understand that any information I give may be investigated as allowed by law or Presidential order. I certify that,

to the best of my knowledge and belief, all of my statements are true, correct, complete, and made in good faith. Misrepresentations of VOSB or SDVOSB eligibility may

result in action taken by VA officials to debar the business concern for a period not to exceed 5 years from contracting with VA as a prime contractor or a subcontractor.

PRIVACY ACT STATEMENT:

The information collected on this form is necessary to meet the eligibility of veteran-owned small business concerns under Section

502 of Public Law 109-461, 38 United States Code (U.S.Code) Section 8127 requirements. We will use the information to identify any VA records. Furnishing the

information on this form, including your Social Security Number (No.) and VA File/Claim No. is voluntary; however, if the information is not furnished, VA will not

recognize your small business as veteran-owned or service-disabled veteran-owned. Your obligation to respond is voluntary.

PAPERWORK REDUCTION ACT NOTICE: The collection of information meets the requirement of 38 U.S.Code Section 8127 (f) 4, as amended

by Section 2 of the Paperwork Reduction Act of 1995. This form has been created to provide an efficient way for the Department of Veterans Affairs to

collect and verify veterans and service-disabled veterans in Vendor Information Pages (VIP). We estimate the time to fill out the form to be about 5

minutes to read the instructions, gather the facts, and answer the questions. VA cannot conduct or sponsor a collection of information unless a valid OMB

control number is displayed. You are not required to respond to a collection of information if this number is not displayed.

0877

VA FORM

SUPERSEDES VA FORM 0877, NOV 2008,

WHICH WILL NOT BE USED.

SEP 2010