ILLINOIS DEPARTMENT OF CENTRAL MANAGEMENT SERVICES
BUSINESS ENTERPRISE PROGRAM / VETERAN BUSINESS PROGRAM
AFFIDAVIT
AFFIRMATIONS
1. Pursuant to the requirements of Illinois Administrative Code, Title 44, PART 10 and/or Part 20, I
understand that I must notify CMS within thirty (30) days of any change affecting my firm’s ability to
meet BEP/VBP program eligibility requirements. I/We understand and acknowledge that to fraudulently
obtain or retain certification or public monies, to willfully make a false statement to an official for the
purpose of influencing certification eligibility or to obstruct or impede an official or employee who is
investing the qualifications of a business which has requested certification is a Class 2 felony
subject to
prosecution under Chapt
er 38, Article 33C of the Criminal Code of the State of Illinois.
2. I/We affirm that the Person with Disabled, Minority, Female and/or veteran interest in the business
constitute the majority control over business operations. Further, the undersigned agrees to provide
written changes in the submitted information after the filling of this application and before the work of this
firm is completed on any agency awarded contract. The agency must be informed in writing of the change,
and failure to do so may result in decertification or denial of certification. The firm must further provide, upon
request, information of any work performed on any specified project regar
ding type of work performed, its
duration, amount of payment to the firm, and to permit the audit and examination of books, records and files
of the named firm.
3. ANY MATERIAL MISREPRESENTATION OF INFORMATION IN THIS DOCUMENT WILL BE
GROUNDS FOR: (1) DENIAL OF CERTIFICATION (2) DECERTIFICATION (3) DEBARMENT (4)
TERMINATING ANY CONTRACT(S) THAT MAY BE AWARDED AND (5) INITIATING ACTION UNDER
FEDERAL AND/OR STATE LAWS CONCERNING FALSE STATEMENTS.
Signature of individual(s) claiming ownership and control at least 51%
of the business MUST sign.
Business Name Business FEIN #
Print Name Print Title Signature Of Owner Date
Print Name Print Title Signature Of Owner Date
Print Name Print Title Signature Of Owner Date
Print Name Print Title Signature Of Owner Date
Notary Seal: Subscribed and sworn to before me this day of , 20
Signed:
Notary Public in and for the County of: State:
My commission expires:
Mail this affidavit and supporting documentation to the Illinois Department of Central Management
Services, Business Enterprise Program, 100 West Randolph Suite 4-100, Chicago Illinois 60601.
.
