Revised June 2019
ANNUAL AFFIDAVIT OF ELIGIBILITY
Certification: DBE MBE WBE ACDBE N
Name of Business:
Owners & Ownership Percentages:
Physical Address (Street/City/State/Zip):
Mailing Address:
Email Address: Webpage:
Business Phone: Cell Phone: Fax:
NAICS Codes: No. of Employees:
INITIAL ALL THAT APPLY:
There have been no changes in ownership or control in the past year.
I am currently certified for the applicable programs in my home state.
The business remains within the SBA size standard for the listed NAICS Codes.
The Personal Net Worth (PNW) of all qualifying owners is less than $1.32 million.
Additional information:
**Attach supplemental documentation to show any changes listed
**Attach a copy of the firm’s completed federal tax return for the previous year OR copy of extension
I swear the statements above are true and correct. I agree to permit the audit and examination of books,
records and files of myself and the firm. I understand any material misrepresentation is grounds for perjury
and subsequent sanctions or prosecution.
Majority Owner Name & Title (print)
Majority Owner Signature
Date
NOTARY CERTIFICATE & SEAL REQUIRED
State of: County of:
The foregoing instrument was subscribed
and sworn before me on this day of
, 20 .
Notary Public Signature
Notary Seal
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