Form: Sb Self Cert - Small Business Self-Certification Form
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4Small Business Self-Certification Form
(see Notes and Definitions, pages 2-4)
KS15051 | Design & Construction of Uranium Processing Facility (UPF), Construction Support Building (CSB)
at the Y-12 National Security Complex, Oak Ridge, TN
WG Project No - Name: ________________ - ________________________________________________________
W912QR-15-R-0047
WG Subcontract No.: ___________________________
Owner Contract No.: ___________________________
Subcontractor / Vendor Name: ______________________________________________________________________
______________________________________________________________________________________________
(Street Address, City, State, Zip)
(Phone)
Scope of Work (Descriptive): ______________________________________________________________________
SBA’s NAICS
Millions $
(e)
NAICS Code
: ___________________________
Threshold (
one)
Employees __________________
(Must be only one full 6 digit code)
(SBA Threshold Value)
(a)
(a)
Sub’s / Vendor’s: (a) Average
(b) Average
Annual Receipts: $
No. of Employees:
(Avg. from Last 3 Competed. Tax Years, Also Ref. 13 CFR 121.104)
(Avg. from Last 12 Months, Also Ref. 13 CFR 121.106)
HAND INITIAL ONE OF THE FOLLOWING:
INITIAL PROPOSAL DATE
(d)
My business ________ IS or ________ IS NOT dominant
in my industry.
____________________________
(Date of Initial Proposal, If Applicable)
HAND INITIAL ONE OF THE FOLLOWING:
SB
or
OTSB (Other Than Small Business a.k.a. Large Business)
IF “SB” INITIALED ABOVE, HAND INITIAL BELOW WHICH ALSO APPLY (IF ANY):
SBA Certified
(1)
(1)
SDB
WOSB
HUBZoneSB
VOSB
SD-VOSB
(initial if SDB8(a))
(also initial VOSB)
(1) If VOSB and/or SD-VOSB initialed above, my business _______ IS or _______ IS NOT VA CVE verified.
HAND INITIAL ALL THAT APPLY (IF ANY):
(2)
ANC/TO
HBCU/MI
AbilityOne
(also initial SB & SDB)
(Per DFAR: also initial SB)
(Per DFAR: also initial SB)
(2) If ANC/TO initialed above, my SDB status _______ HAS or _______ HAS NOT been verified by the SBA.
Undersigned certifies that information provided is accurate and understands applicable small business rules, regulations, and definitions. Under 15
U.S.C. 645(d) and 13 CFR 121.108, size misrepresentation is subject to (1) suspension and debarment, (2) civil penalties, and (3) criminal penalties.
(Typed Name: Owner, Principal, or Officer)
(Title)
(Email)
(Signature: Hand or Authenticated Elec.)
(Date)
“X” is acceptable, in lieu of “HAND INITIAL”, if this form is completed and signed with an authenticated electronic signature.
(Return of Pages 2-4 Not Required)
Page 1 of 4
Form: SB SELF CERT
Revision Date: September 24, 2015
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