Form Committee Form 404 Committee Form 404 Annual Certification - Qualified Nonprofit Agency Servin

ANNUAL CERTIFICATION – QUALIFIED NONPROFIT AGENCY SERVING PEOPLE WHO ARE SEVERELY DISABLED			APPROVED OMB NO. 3037-0002 EXPIRES
TO: COMMITTEE FOR PURCHASE FROM PEOPLE WHO ARE BLIND OR SEVERELY DISABLED
1. NAME OF AGENCY:
2. ADDRESS:
3. PHONE:		4. FISCAL YEAR ENDING:
5. WE CERTIFY THAT: A. Data in Items 6A and 7A are the direct labor hours paid to employees of the agency who are blind or have other severe disabilities as defined in 41 CFR 51-1.3 of the Committee regulations. Data in items 6B and 7B are the direct labor of people who do not meet the Committee's definition of blind or otherwise severely disabled. Both sets of hours include vacation, holiday and paid sick leave. Any direct labor performed by temporary employees or agencies is included. (If direct labor hours were performed at addresses other than that in item 2, list all additional location(s) on a separate page.) B. There is a file containing adequate evidence of disability and an annual review for competitive employability on each direct labor employee who is blind or has other severe disabilities, including both JWOD and non-JWOD, verifying that the individual meets the Committee's criteria per 41 CFR 51-4.3. (If any of these files are located at an address(es) other than that in item 2, list additional location(s) on a separate page.) C. An ongoing placement program as required by 41 CFR 51-4.3 is operated by or for the agency. D. The agency is in compliance with applicable Occupational Safety and Health Act (OSHA) standards as prescribed by the Secretary of Labor. The agency has, at a minimum, a hazard safety plan. (If the agency was inspected and citations were received, attached the inspector's report.) E. Have there been any changes to your corporate Articles/State Statues or Bylaws/Implementing Regs. During the most recent fiscal year? Yes ____ No ____. If yes, 1) Dates(s) of change: Articles/State Statutes _______ Bylaws/Implementing Regs. _________: and 2) Copies of changes are attached ___OR changes were submitted to the Committee on ____________. The data on this form reflect agency operations for the fiscal year indicated in item 4, and all of the data (including the data provided on the total compensation, cash and noncash, to the agency’s key employees) is complete and accurate. No net income inures to the benefit of any key employee or other individual(s). If yes, please explain in an attached document. Does the agency meet the Committee-approved accountability standards, as provided in 41 CFR 51-4 of the Committee regulations? Yes ____ No ____. If no, attach an explanation and relevant documentation showing your progress toward meeting those standards. THIS CERTIFICATION CONCERNS A MATTER WITHIN THE JURISDICTION OF AN AGENCY OF THE UNITED STATES AND THE MAKING OF FALSE, FICTITIOUS, OR FRAUDULENT CERTIFICATION MAY RENDER THE MAKER SUBJECT TO PROSECUTION UNDER TITLE 18 USC 1001.
SIGNATURE – OFFICER OF BOARD (SIGN)→	DATE	SIGNATURE – AGENCY EXECUTIVE (SIGN)→		DATE
NAME: (PRINT)		NAME: (PRINT)
TITLE: (PRINT)		TITLE: (PRINT)
		EMAIL ADDRESS:
NISH REVIEW
SIGNATURE – NISH OFFICER (SIGN)→		DATE:
NAME: (PRINT)
TITLE: (PRINT)

COMMITTEE FORM 404 (Rev 01/2007)

ANNUAL AGENCY OPERATIONS (Page 1 of 3)

ANNUAL AGENCY OPERATIONS

Fiscal Year Ending September 30, ______

6. INCLUDE IN THIS SECTION DATA FOR TOTAL AGENCY
				HOURS				PERCENT
A. Direct labor hours paid to people with severe disabilities
B. Direct labor hours paid to people without severe disabilities
C. Total direct labor hours (A + B)
				Blind				Total
D. Total number of severely disabled direct labor employees (regardless of hours worked)
7. INCLUDE IN THIS SECTION DATA FOR WORK PERFORMED UNDER JAVITS-WAGNER-O'DAY ACT/ABILITYONE PROGRAM ONLY
		PRODUCTS				SERVICES
A. Direct labor hours paid to people with severe disabilities
B. Direct labor hours paid to people without severe disabilities
C. Total direct labor hours (A + B)
D. Percent of direct labor by people with severe disabilities
E. Number of people who are blind working in:
F. Total number of people with severe disabilities: (regardless of hours worked and including those in 7E)
G. AbilityOne direct labor wages paid to people with severe disabilities (Include Health and Welfare [cash payments only], vacation, holiday and sick leave pay)								$
8. INCLUDE IN THIS SECTION INFORMATION ON AGENCY AND ABILITYONE PLACEMENT AND PROMOTION OF PEOPLE WITH SEVERE DISABILITIES
	ABILITY ONE		NON- ABILITY ONE				DIRECT PLACEMENT		TOTAL
A. Placed into competitive employment from
B. Placed into supported employment from
C. Promoted into a new job, other than supervisory or management positions, that included increased wages and/or benefits, not cost of living raises or productivity increases
D. Promoted into a new job requiring supervisory, management or technical skills, that included increased wages and/or benefits, not cost of living raises or productivity increases
9. AGENCY AND ABILITYONE SALES DATA
A. Sales of procurement List Items
1. Military Resale (Direct)
2. Sales from AbilityOne Products
3. Sales from AbilityOne Services
4. Total AbilityOne Sales
B. Base Supply Centers
C. Other Federal Sales
D. Other Sales and Subcontracting
E. Total Agency Sales

COMMITTEE FORM 404 (Rev 01/2007)

ANNUAL AGENCY OPERATIONS (Page 2 of 3)

ANNUAL AGENCY OPERATIONS

Fiscal Year Ending September 30, _____

10. TOTAL COMPENSATION (CASH AND NONCASH) PAID TO KEY EMPLOYEES
(A) Name and address of each key employee	(B) Title and average hours per week devoted to position	(C) Compensation	(D) Contributions to employee benefit plans and deferred compensation	(E) Expense account and other allowances
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COMMITTEE FORM 404 (Rev 01/2007)

ANNUAL AGENCY OPERATIONS (Page 3 of 3)