Form Approved, OMB No. 2900-0675
Expiration Date: July 31, 2024
Respondent Burden: 30 Minutes
VETBIZ VENDOR INFORMATION PAGES VERIFICATION PROGRAM
INSTRUCTIONS: Please provide the name of the company and its Data Universal Numbering System (DUNS) number. All stockholders/owners must provide title, First,
Last, Middle Name, Percentage of Business Ownership, Veteran Status, Social Security Number or File Number, Date of Birth (SSN/File Number and DOB only apply to
Veterans, Service Disabled Veteran or eligible Surviving Spouse) and sign the form. Ownership must equal 99-100%. VA will not accept applications from owners/
stockholders who are not Veterans, Service-Disabled Veterans or eligible Survivng Spouses. DO NOT MAIL, EMAIL or FAX the form.
PART I - CONSENT TO ACCESS AND VERIFY VETERAN(S) OWNER(S)/VETERAN(S) STOCKHOLDER(S) RECORD(S)
Each veteran owner/Veteran stockholder named herein authorizes consent for the Center for Verification and Evaluation (CVE) personnel to access and verify their records.
CVE will match your information with records maintained by the Veterans Benefits Administration (VBA).
NAME OF COMPANY DBA DUNS
NAME(S) OF EACH
BUSINESS OWNER/STOCKHOLDER/
SURVIVING SPOUSE
(Mr./Ms., First name, Middle, Last, Jr./Sr./III)
% OF
OWNER-
SHIP
VETERAN STATUS
VETERAN
SVC. DIS.
VETERAN
SPOUSE
NON-VET
SSN/VA FILE NO./CLAIM
NO. FOR VETERAN(S) &
SERVICE DISABLED
VETERANS &
SURVIVING SPOUSE
ONLY
(Skip if Non-Veteran)
DATE OF
BIRTH
(MM/DD/YYYY)
SIGNATURE OF EACH
BUSINESS
OWNER(S)
DATE
SIGNED
PART II - AFFIRMATION
By signing this form, I affirm that the legal documents establishing the business are, to the extent required, filed with my state and such legal documents establish that at
least 51% of the business is owned and controlled (or in the case of stock, at least 51% of the stock is owned) by Veterans or Service-Disabled Veterans, or eligible
Surviving Spouses, as stated in Public Law 109-461, as amended by Public Law 111-275 and Public Law 114-328, 38 U.S. Code Section 8127. I affirm that each of the
owners of the business (or in the case of a business with stock, each of the stockholders) is eligible to participate in Federal contracting and that neither the business nor any
of the individual owners have any active exclusions as listed in the System for Award Management database or otherwise. I further affirm that I have read and understand
the language in 38 CFR part 74 and 13 CFR part 125 and that the business is controlled by individuals eligible to participate in the Vendor Information Pages Verification
Program, if I am claiming Veteran-Owned Small Business (VOSB) or Service-Disabled Veteran-Owned Small Business (SDVOSB) status. A false statement on any part of
your application may be punished by fine or imprisonment (U.S. Code title 18, section 1001). I understand that any information I give may be investigated as allowed by
law or Presidential order. I certify that, to the best of my knowledge and belief, all of my statements are true, correct, complete, and made in good faith. Misrepresentations
of VOSB or SDVOSB eligibility may result in action taken by VA officials to debar the business concern for a period not to exceed 5 years from contracting with VA as a
prime contractor or a subcontractor.
PRIVACY ACT STATEMENT: The Privacy Act of 1974, 5 U.S.C. 522a(e), requires that all agencies publish in the Federal Register, a notice of the existence and
character of their systems of records. VA system of records entitled VA Vendor Information Pages (123VA00VE) covers the information being provided on this form. The
information collected on this form is necessary to meet the eligibility requirements for Veteran, Service-Disabled Veteran, and Surviving Spouse owned small business
concerns under Public Law 109-461, as amended by Public Law 111-275 and Public Law 114-328, 38 U.S. Code Section 8127. We will use the information to identify any
VA records. Furnishing the information on this form, including your Social Security Number (No.) and VA File/Claim No. is voluntary; however, if the information is not
furnished, VA will not recognize your small business as Veteran-Owned or Service-Disabled Veteran-Owned. Your obligation to respond is voluntary.
PAPERWORK REDUCTION ACT NOTICE: The collection of information meets the requirement of Public Law 109-461, as amended by Public Law 111-275 and
Public Law 114-328, 38 U.S. Code Section 8127, and by Section 2 of the Paperwork Reduction Act of 1995. This form has been created to provide an efficient way for the
Department of Veterans Affairs to collect and verify Veterans in the Vendor Information Pages. We estimate the time to fill out the form to be about 30 minutes to read the
instructions, gather the facts, and answer the questions. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are
not required to respond to a collection of information if this number is not displayed.
VA FORM
JUL 2021
0877
SUPERSEDES VA FORM 0877, JULY 2017,
WHICH WILL NOT BE USED.
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