Disclosure Affidavit

In order to evaluate the legitimacy of each DDE applicant, it is required that certain relevant information be provided initially, prior to award, and be continually updated throughout contract performance. This information must include statements clearly identifying and explaining the extent of the DBE ownership and control including, but not limited to, the information items on this form. All information items must be furnished or properly addressed before the business entity can be evaluated. Definitions: Disadvantaged Business means a small business concern: (a) which is at least fifty-one (51%) percent owned by one or more socially and economically disadvantaged individuals, or, in the case of any publicly owned business, at least fifty-one (51%) percent of the stock of which is owned by one or more socially and economically disadvantaged individuals; and (b) whose management and daily business operations are controlled by one or more of the socially and economically disadvantaged individuals who own it. Socially and Economically Disadvantaged Individuals means those individuals who are citizens of the United States (or lawfully admitted permanent residents) and who are women, Black Americans, Hispanic Americans, Native Americans, Asian-Pacific Americans, or Asian-Indian Americans and any other minorities or individuals found to be disadvantaged by the small business administration pursuant to Section 8 (a) of the Small Business Act. 1. Name of business (applicant firm) __________________________________________________________ Address ______________________________________________________________________________ City State Zip Phone Number (including area code) _______________________________________________________ 2. Type of ownership (check one) ( ) Sole Proprietorship ( ) Partnership ( ) Corporation ( ) Joint Venture 3. Name and Address of Attorney ___________________________________________________________ ( )_______________________________________________________________________________ Telephone Number 4. Name and Address of CPA or Accountant __________________________________________________ Telephone Number 5. Nature of business ____________________________________________________________________ 6. Years of business _____________________________________________________________________ 7. Percent of DBE ownership _____________________________________________________________ 8. Is any DBE not a citizen of the U.S.? If yes, provide name(s) of owner(s). If none, so state. __________ 9. Identification of 0 ownership in terms of name of individuals or corporations and their percent of ownership: Years of Ownership Voting CERTIFICATION OF DISADVANTAGED BUSINESS ENTERPRISES CHAPTER 1680-8-1 AND WOMEN BUSINESS ENTERPRISES Owners Race Sex Ownership Percentage Percentage _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ 10. If any owner of the applicant firm also has an ownership interest in another firm, indicate: Nature of Relationship to Name of Owner Other Ownership Interest Applicant Firm ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ 11. Please Complete: The names of the Officers of the Company are: Date Elected __________________________________________ __________________________ President __________________________________________ __________________________ Vice President __________________________________________ __________________________ Secretary __________________________________________ __________________________ Treasurer __________________________________________ __________________________ Other 12. Current Board of Directors Minority Home Address Name or Female Date Elected Number, Street, City, State, Zip ________________________ __________________ ___________ _________________________ ________________________ __________________ ___________ _________________________ ________________________ __________________ ___________ _________________________ 13. Prior Board of Directors Minority Home Address Name or Female Date Elected Number, Street, City, State, Zip ________________________ __________________ ___________ _________________________ ________________________ __________________ ___________ _________________________ ________________________ __________________ ___________ _________________________ 14. Shareholders Minority Amount Indicate Loans Class Common Total Date of Name or Female Paid or Notes or Preferred Cost Ownership _________ ___________ ___________ ___________ ___________ __________ ________ _________ ___________ ___________ ___________ ___________ __________ ________ CERTIFICATION OF DISADVANTAGED BUSINESS ENTERPRISES CHAPTER 1680-8-1 AND WOMEN BUSINESS ENTERPRISES _________ ___________ ___________ ___________ ___________ __________ ________ 15. In the instance of each share of stock secured through a purchase agreement, a loan, or a note, provide copy of agreement, loan or note. Copy must indicate source of loan, date of loan, conditions relating to distribution of profits and management of business, and collateral or guarantees given as security. 16. If your firm is owned in full or in part by a company listed in item 14, list on a separate sheet that company’s shareholders to include percentage of ownership interest and the names and address of directors and officers. 17. List all sources and amounts of money loaned to the corporation. Source Amount _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ 18. Identify your current bonding company and bank. Do you have letter(s) of credit? If so, identify. Bonding Company Bank Letters of Credit _________________________ ___________________________ ____________________________ _________________________ ___________________________ ____________________________ _________________________ ___________________________ ____________________________ 19. What is your bonding limit? $ ____________________________________________________________________________________ 20. Who determines what jobs/contracts the company will undertake? (Name and Title) _____________________________________________________________________________________ 21. Who will be responsible for on-site project supervision? (Name and Title) _____________________________________________________________________________________ 22. Who negotiates and signs for surety bonds and who signs for insurance and payroll? Surety and/or Performance Bonds Insurance Payroll ____________________________ _______________________ _____________________________ ____________________________ _______________________ _____________________________ 23. Detail any limitations on authority of any official to sign checks, including amount of check and multiple signature requirement. _________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 24. Prior and current company clients (Company Name, Street Address, City, State, Zip) (Attach list if necessary). _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ CERTIFICATION OF DISADVANTAGED BUSINESS ENTERPRISES CHAPTER 1680-8-1 AND WOMEN BUSINESS ENTERPRISES 25. List current and past subcontractors (Attach list if necessary) Current Past _____________________________________________ _____________________________________ _____________________________________________ _____________________________________ _____________________________________________ _____________________________________ 26. Does your company own major equipment? If no, write no ___________ If yes, write yes ___________ And list the major equipment owned. Do not list rental or leased equipment. Type Quantity __________________________________________________ _________________________________ __________________________________________________ _________________________________ __________________________________________________ _________________________________ 27. List all products and/or services rendered. 28. Has your firm been approved by the Federal Small Business Administration 8 (a) program? __________ Yes __________ No If yes, supply copy of approval letter. 29. Identification of any owner OF management official of the business entity who is or has been an employee of another firm that has an ownership interest in or a present business relationship with the business entity. Present business relationship include shared space, equipment, financing, or employees as well as both firms having some of the same owners. 30. Previous certifications or denials of certification as a minority business enterprise: ( ) Enclosed ( ) Not Enclosed ( ) Non Previously Issued 31. Will another contractor (prime contractor, subcontractor, and/or supplier) provide any assistance to the applicant firm? (If no, so indicate; if yes, provide details). Assistance Details Supervision at job site Hiring and/or firing Purchase of supplies/materials Provide office space, telephone, bookkeeping, payroll, tax withholding on other services Personnel manpower Payroll and worker’s compensation 32. Identification of any stock options or other ownership options that are any outstanding loans between owners or between owners and third parties relevant to the business entity. Describe below or enclose statement. If none, please affirm the following statement by handwriting it: “There are no stock options or other ownership options currently outstanding, nor any loans between owners or between owners and third parties relevant to the firm which I represent and for which I make this DBE application.” _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ CERTIFICATION OF DISADVANTAGED BUSINESS ENTERPRISES CHAPTER 1680-8-1 AND WOMEN BUSINESS ENTERPRISES _________________________________________________________________________ 33. Identification of control of business entity; list those individuals who are responsible for day-to-day management and policy decision making including, but not limited to those with prime responsibility for: Name Race Sex Title Financial Decision Management Decision* Supervision of Field Operations *Including, but not limited to, estimating. marketing and sales, hiring and firing of management personnel, and purchasing of major items or supplies. Brief summary of information listed above: Name Experience and Qualifications in relationship to Responsibilities Number of Years With Firm 34. All oral and tacit agreements shall be reduced to writing and submitted with this affidavit. Such agreements may include, but not be limited to the ownership of voting securities, buy-out rights, agreements affecting voting rights of shareholders, loan agreements, equipment rental, management services agreements, etc. If there are no written, oral or tacit agreements concerning the operation of the company between any person associated with company, please affirm the following statement by handwriting it “There are no written oral or tacit agreements concerning the operation of the company between any persons associated with the company.” _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________ 35. Submit the following documents (and any amendments thereto) with this affidavit. For A Corporation FOR A PARTNERSHIP a. Last two year’s financial statement prepared by an independent CPA or accountant a. Last two year’s financial statement prepared by an independent CPA or accountant b. Prior two years federal corporate tax returns including all schedules b. Prior two years federal corporate tax returns including all schedules CERTIFICATION OF DISADVANTAGED BUSINESS ENTERPRISES CHAPTER 1680-8-1 AND WOMEN BUSINESS ENTERPRISES c. Resumes of principals of your company showing education, training and employment with dates c. Resumes of all partners showing education, training and employment with dates d. License to do business in Tennessee and any other necessary licenses d. License to do business in Tennessee e. Articles of Incorporation, including date approved by State, and any subsequent amendments e. Partnership agreement f. Minutes of first corporate organizational meeting f. Buy out rights agreement g. Corporation By-Laws g. Profit sharing agreement h. Copy of stock certificate(s) issued (not a specimen copy) h. Proof of capital invested i. Stock ledger i. If other than Female or Black, proof of minority status j. Proof of stock purchase k. Copies of third party agreements such as rental or management service agreements, etc. l. If other than Female or Black, proof of minority status In addition, for both corporation and partnership, submit all agreements relating to: a. Stock options e. Stockholders voting rights b. Ownership options f. Restrictions on the disposal of stock loan agreements c. Stockholders agreements g. Facts pertaining to the value of shares d. Buy-out fights h. Ownership of voting securities I HEREBY DECLARE AND AFFIRM THAT I am the ________________________________________ duly (Title) authorized representative of (the firm of) _________________________________________________Name of Firm I hereby declare and affirm that I am a disadvantaged business enterprise (DBE) as defined by 49 CFR, Part 23, and 23.62 (amended) and that I will provide information requested by the Tennessee Department of Transportation to document this fact. The undersigned does hereby swear that the foregoing statements are true and correct and include all materials and information necessary to identify and explain the operations of ___________________________________ Name of Firm as well as the ownership thereof. Further, the undersigned does covenant and agree to provide to the Tennessee Department of Transportation complete and accurate information regarding actual work performed on projects, the payment therefor and any proposed changes in any of the arrangements hereinabove stated and to permit the audit and examination of the books, records and files of _________________________________________________________________ by Name of Firm authorized representatives of the Tennessee Department of Transportation or the Federal Government. It is recognized and acknowledged that the statements herein are being given under oath and any material CERTIFICATION OF DISADVANTAGED BUSINESS ENTERPRISES CHAPTER 1680-8-1 AND WOMEN BUSINESS ENTERPRISES misrepresentation will be grounds for terminating any contract which may be awarded in reliance hereon and for initiating action under federal and state laws concerning false statements. I DO SOLEMNLY DECLARE AND AFFIRM UNDER THE PENALTIES OF PERJURY THAT THE CONTENTS OF THE FOREGOING DOCUMENT ARE TRUE AND CORRECT, AND THAT I AM AUTHORIZED, ON BEHALF OF THE ABOVE FIRM, TO MAKE THIS AFFIDAVIT. _____________________________________________________ Signature-Company’s Authorized Representative STATE OF _________________________________ COUNTY OF _______________________________ On this __________day of ____________________, 19 __________, before me, _______________________ personally appeared ________________________ , known to me to be the person described in the foregoing Affidavit and acknowledge that he (she) executed the same in the capacity herein stated and for the purposes therein contained. In witness thereof, I hereunto set my hand and official seal. ___________________________________________ (Notary Public) My Commission Expires _________________________________ (Seal)