Form Asd 22242 - Application For Resident Veteran Business Certification (Page 2 of 4) in pdf

Previously Certified Business or Purchased, Reorganized, Name Changed Business

The business is licensed to do business in New Mexico; and

After January 1, 2012, but less than three years ago, the business obtained and was eligible for resident business certi-

fication. However, the business has since: (1) changed its name; (2) reorganized into one or more different legal enti-

ties; or (3) been purchased by or merged with another legal entity, but now operates in New Mexico as substantially

the same commercial enterprise;

After January 1, 2012, but less than three years ago, the business applied and was eligible for resident business cer-

tification. However, before the Department was able to issue certification, the business: (1) changed its name; (2)

reorganized into one or more different legal entities; or (3) was purchased by or merged with another legal entity, but

now operates in New Mexico as substantially the same commercial enterprise.

Annual Revenue and Documentation

SECTION III

Please provide the business’ previous year’s annual revenues below and attach the required documents. If the required

documents are attached, please place a checkmark next to the second statement below. An application submitted without

the required information and documentation will be incomplete.

The previous year’s annual revenues of the resident veteran business are $_____________________; and

Attached to this application is verification by the Federal Dept. of Veterans Affairs that the business is either a veter-

an-owned small business or a service-disabled veteran-owned small business;

Attached to this application is proof that a veteran or veterans own a majority of the business and verification of

either (1) veteran status as indicated by the U.S. Dept. of Defense DD Form 214 of release or discharge from active

duty with an honorable discharge or (2) service disabled-veteran status by the Dept. of Veterans Affairs.

AND

Any applicant provided a certificate of Resident Veterans Preference by the Taxation and Revenue Department as

either a business or a contractor under the provisions of Sections 13-1-21 or 13-1-22 NMSA 1978, agrees that when

awarded a contract involving a Veterans Preference during the last calendar year beginning on January 1 and end-

ing on December 31, to report the award amount involved to the State Purchasing Division of the General Services

Department. The report will be given under the penalty of perjury and indicate whether the awarded amount was as a

purchase from a public body, or as a public works contract from a public body, as the case may be.

Affidavit

SECTION IV

AFFIDAVIT FROM CERTIFIED PUBLIC ACCOUNTANT

I hereby swear, under oath that it is my professional opinion that the applicant

STATE OF __________________

meets the required criteria set forth in NMSA 1978, Section 13-1-22 (2012) for

Resident Veteran Business Certification and that ALL information provided and

COUNTY OF ________________

ALL checkmarked statements in the foregoing application are true and com-

plete to the best of my knowledge.

Name

Date

State

CPA License #

Signature

NOTARY

Subscribed and sworn to before me this __________ day of _________________________, 20_________ .

Notary Public _____________________________

My Commission Expires __________________

(NOTARY SEAL)

I am authorized to sign this application on behalf of the applicant and attest to the truthfulness of

the information provided herein.

Signature of Applicant

Date

Please see last of instructions; APPLICATION AND FEE SUBMISSION for correct mailing address and fee.

Form Asd 22242 - Application For Resident Veteran Business Certification Page 2

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