Sworn Affidavit - B-Bbee Exempted Micro Enterprise Form

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SWORN AFFIDAVIT – B-BBEE EXEMPTED MICRO ENTERPRISE
I, the undersigned,
Full name & Surname
Identity number
Hereby declare under oath as follows:
1. The contents of this statement are to the best of my knowledge a true reflection of the facts.
2.
I am a member / director / owner of the following enterprise and am duly authorised to act on
its behalf:
Enterprise Name
Trading Name
Registration Number
Enterprise Address
3. I hereby declare under oath that:
The enterprise is ______________% black owned;
The enterprise is ______________% black woman owned;
Based on the management accounts and other information available on the _______ financial
year, the income did not exceed R10,000,000.00 (ten million rands);
Please confirm on the table below the B-BBEE level contributor, by ticking the applicable
box.
100% black owned
Level One (135% B-BBEE procurement recognition)
More than 51% black
Level Two (125% B-BBEE procurement recognition)
owned
Less than 51% black
Level Four (100% B-BBEE procurement recognition)
owned
4. The entity is an empowering supplier in terms of the dti Codes of Good Practice.
5. I know and understand the contents of this affidavit and I have no objection to take the
prescribed oath and consider the oath binding on my conscience and on the owners of the
enterprise which I represent in this matter.
6. The sworn affidavit will be valid for a period of 12 months from the date signed by
commissioner.
Deponent Signature:
Date:
Commissioner of Oaths
Signature & stamp

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