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V.I. Department of Public Works (VIDPW) Unified Certification Form Note: Do Not Use This Form for New Applications – ANNUAL UPDATES ONLY For Calendar Year Name of Firm: Mailing Address: City: State: Zip: Physical Address: City: State: Zip: Office Telephone: Alternate Telephone: Office Fax: Federal ID Number: Email: Web Address: Please submit the following documents with your Affidavit for Continuing DBE Certification: Documents Time Period Required Attached (Check if Yes) Firm’s complete signed Federal Tax Return (with schedules & attachments) Current Year Yes Complete signed Federal Tax Returns for all business affiliations of the owner(s) Current Year Yes Current Employees: (Report number only of Full Time, Part Time and temporary employees as of year-end reporting period) During past 12 Months Yes The following Information Should Be Submitted Only If There Have Been Changes in the Items Listed or in the Ownership, Structure and/or Operations of the Firm. Additional Documents (if applicable) Time Period Required Attached (Check if Yes) New Owners (Include a description of their responsibilities, investment made to acquire ownership and documentation of contribution) Since last Certification Yes Owners/Employees involved in another business: (Indicate the other firm’s name; owner/employee name; type of business and the nature of the business relationship – i.e., current owner, employee or previous owner) Since last certification Yes Articles of Incorporation: (if amended) Since last certification Yes By-Laws: (if amended) Since last certification Yes Equipment List: (Updated List, for purchase or lease of new equipment) Since last certification Yes Vehicle Information: (Trucking & Construction firms): Submit new or updated vehicle information listing the (1) Type, (2) Serial Numbers & purchase agreements for equipment; (3) Lease, rental and lease, rental & purchase agreements (e.g., if lease to own); and (4) Insurance documents for the equipment Since last certification Yes Significant Changes: (Explain changes in the business on a separate sheet of paper and attach to this document) Since last certification Yes New Work Area/Services – REQUEST ADDITIONAL NAICS CODES: (Request to add additional NAICS Code(s), submit copies of three executed contracts and include NAICS Code (if known). For further information on this, review NAICS website at http://www.sba.gov/size/) ) Since last certification Yes Page 2 - DBE ANNUAL “NO CHANGE” AFFIDAVIT Upon penalty of perjury, the undersigned certifies that he/she is the __________________________________ (Title in Firm) of ______________________________________ (Firm’s Name) and that he/she is authorized by the firm to execute this affidavit in its behalf and attests to the accuracy and truthfulness of the information on the affidavit and its supporting documentation. Affiant(s) also understands that information provided herein may be audited, shared or verified by other means with other city, state or federal agencies as provided by law. Affiant(s) affirm that the Personal Net Worth of the majority owner(s) does not exceed $1.32 million threshold as required by 49 CFR, Part 26.67. Affiant(s) also affirms that the disadvantaged, minority or women interests in the business constitutes 51% majority control over business operations and further affirms that there have been no changes in the circumstances of _________________________________________ (Firm’s name) affecting the ability to meet size, disadvantaged status, ownership, or control requirements of 49 CFR, Part 26. There have been no material changes in the information provided with the original application for certification, except for any changes in which you have provided written notice under 49 CFR Part 26.83(1). The applicant and its affiliates continue to meet the Small Business Administration (SBA) criteria for being a small business concern and its average annual gross receipts (pursuant to SBA, NAICS size limits), in addition to ensuring the firm’s previous three year average, does not exceed the USDOT, $23.98 million in gross annual receipts for DBE firms, (or $56.42 million annual gross receipts for Airport Concessionaire Disadvantaged Business Enterprise firms). The undersigned also agrees to inform in writing of any circumstances affecting its ability to meet size, disadvantaged status, and ownership or control requirements of this part or any material change in the information provided in your application form. Change notices must take the form of a notarized affidavit, sworn to by the applicant, executed under penalty of perjury of the laws of the United States. Applicant must provide notification WRITTEN NOTIFICATION within 30 days of the occurrence of the change. Failure to make timely notification of such changes will deem the firm to have failed to cooperate under section 26.109(c). Under Section 26.107 of 49 CFR, Part 26: If at any time the Department or a Recipient has reason to believe that any firm that does not meet the eligibility criteria of Subpart D, Certification Standards, and attempts to participate in a DOT assisted program as a DBE on the basis of false, fraudulent, or deceitful statements or representations or under circumstances indicating a serious lack of business integrity or honesty, the Department may initiate suspension or debarment proceedings against you under 49 CFR, part 29. The Department may also take enforcement action under 49 CFR, Part 31, Program Fraud and Civil Remedies, against any participant in the DBE Program whose conduct is subject to such action. The Department may refer to the Department of Justice, for prosecution under U.S.C. 1001 or other applicable provisions of law, any person who makes a false or fraudulent statement in connection with participation of a DBE in any DOT assisted program or otherwise violates applicable Federal Statutes. Any material misrepresentation of information in this document will be grounds for: (1) Denial of Certification; (2) Decertification / Removal of Eligibility; (3) Debarment; (4) Termination of any contract which may be awarded; and (5) Initiating action under Federal or State Laws concerning false statements. (All Owners Must Sign. Attach additional sheet if necessary) __________________________________________________ _________________ (Signature of Owner, Title) Date _________________________________________________ _________________ (Signature of Owner, Title) Date _________________________________________________ _________________ (Signature of Owner, Title) Date _________________________________________________ _________________ (Signature of Owner, Title) 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:____________________________ (SEAL) Rev. 1-2016