Revised 8/2014
Cook County Government
M/WBE Reciprocal Certification Affidavit
Firm Name __________________________________________________________________________
Address _____________________________________ City____________________________________
County___________________________ State ________________________ Zip __________________
Phone (_______)_______________________ Email __________________________________________
I __________________________________________, ________________________________________
(Authorized Representative) (Print Title)
of _________________________________________ do hereby affirm:
(Name of Firm)
1) ________________________________________ is a Minority and/or Women Business Enterprise
(Name of Firm)
currently certified by the City of Chicago as: [ ] Black- [ ] Hispanic- [ ] Asian- [ ] Woman-owned
business.
2) With respect to __________________________________, the personal net worth of the qualifying
(Name of Firm)
(51%) individual(s) does not exceed $2,210,847, excluding the individual’s ownership interest in the
M/WBE firm and the equity of the owner’s primary residence, and otherwise meets the requirements
of Chapter 34, Article IV of the Cook County Procurement Code. (As per Section 34-263 of the
Cook County Procurement Code, an individual’s personal net worth includes only his or her own
Share of assets held jointly or as community/marital property with the individual’s spouse.)
3) The average annual gross receipts of _________________________________________,
(Name of Firm)
as derived from tax filings over the five most recent years, does not exceed the Small Business Size
Standards published by the U.S. Small Business Administration found in Title 13, Code of Federal
Regulations, Part 121. (http://www.sba.gov/content/small-business-size-standards)
Upon penalty of perjury, I __________________________________ affirm that, to the best of my
(Authorized Representative)
knowledge and belief, the information herein is true and accurate.
Signature_______________________________ Title___________________________ Date______________
Subscribed and sworn to before me this __________ day of __________________/ _________
(Month) (Year)
____________________________
(Notary’s Signature) Notary’s Seal
My Commission Expires ___________________________
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