Form FORM 1531 FORM 1531 Small Business Administration: Application For Certifica

Control No. 3245-0225
Exp. Date: 9/30/2007

SMALL BUSINESS ADMINISTRATION

APPLICATION FOR CERTIFICATE OF COMPETENCY

COC Case Number:

Instructions: The Certificate of Compentency (COC) program allows a small business to appeal a contracting officer's determination that it is unable to fulfill the
requirements of a specific government procurement (or sale) contract on which it is the apparent low bidder. This form (SBA Form 1531) should be completed by a
small business concern seeking a COC determination from SBA that it is responsible to perform the specific contract. Applicants must complete items 11-19 and Parts II
and III of this form (SBA will complete items 1-10). The completed form must be submitted to an Area Director serving your area. Visit http://www.sba.gov/aboutsba/
sbaprograms/gc/programs/gc_certificate_competency.html and click on the following "Contacts and Representatives" and Certificate of Competency Program to locate
an Area Director in your area.
Basis of Referral:
PART I
Capacity
Credit
T&P
Int.
1. U.S. Small Business Administration (Office)
Procurement Designation (IFB, RFP or other number)
Restricted

Unrestricted

2. Next Low Bidder -- Whether large or small business, price difference.
3. Name and Address of Contracting Agency

Buyer

a.

Quantity

Phone

b.

Increase Option

C/O
Phone

c.
d.
e.

Unit Price
Total Bid
Progress Payments
Available?

4. Name of Company, Address (Street, City State, ZIP Code)

5. Telephone No. (Include Area Code)

Principal Company Officials (Attach Resumes)
Name
Title

County:

6. Work Performance Location, if different from the above address
(Street, City, State, ZIP Code)

7. Telephone No. (Include Area Code)

Functions at Location

County:

Contact Name:

8. Brief Description of Solicited Items or Services

9. What are contract delivery and special provision requirements of contract?

10. Applicant's directly related experience to solicited items/services

11. Percentage of Government contracts in relation to total sales over 3
yrs
Without
12.
Number of Employees
CoC Contract

%
With CoC
Contract

Attach a list of all current commercial contracts and all
government contracts for past 3 years.
Hours of Work

Administrative and Management

No. of Shifts

Production

Hours per Shift

Other

Employees per Shift
Days per Week

Total
13. Are special skills required?
SBA Form 1531 (11-07) Previous Editions Obsolete

Yes

No

Total Manhours per week
Are Employees with necessary skills
available?

Without
CoC Contract

With CoC
Contract

Yes

No

FACILITIES AND EQUIPMENT
14.

Facility

Area in sq. ft.

List Machinery & Equipment required for this CoC Contract currently available.
List separately additional equipment to be acquired. Use separate sheet if
necessary.

Add'l. for CoC
Contract

Present

(1) Administrative
(2) Manufacturing
(3) Storage - inside
- outside
(4) Other - (specify)

Total
15. Give percentage (dollarwise) of Inventory on hand for the proposed contract

%.

16. Total amount of proposed contract to be subcontracted $

%.

PLANT LOADING AND PRODUCTION SCHEDULES
17.

Total Projected Plant Load Chart (Use a separate line for each existing and proposed contract and each item of present and projected commercial
production. Show start and finish of each item by drawing a line between the month or week started and the month or week to be finished. Use
separate spread sheet if greater detail is needed to evaluate capacity.)
Schedule Periods are in

Months.
1

2

3

Weeks.
4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

A. Commercial
B. Government
C.

CoC Application Contract
D. Other
Present explanation for production and scheduling overlaps; explain delinquent contracts

COST ANALYSIS
18. Check basis

Unit Price,

Total Contract

Direct Material
Direct Labor g

Contingencies
Other (Specify)

Subcontracting
G&A

Profit

Overhead

Total
SBA USE ONLY

19. Based on data contained in the foregoing and in the attached enclosures a CoC is
Recommended

I Concur

Not Recommended

I Do Not Concur (State reasons in items)

By
Signature
Title
Date

Reviewing
Official

Title
Date

According to the paperwork Reduction Act you are not required to respond to this collection of information unless it displays a currently valid OMB Control Number. The number
for this collection is 3245-0225. The estimated burden for completing this form, including time for reviewing instructions, gathering data needed, and completing and reviewing this
form is 8 hours per response. Comments or questions on the burden estimates should be sent to U.S. Small Business Administration, Chief, AIB, 409 3rd St., SW, Washington
DC 20416.

PART II
1. Name of Applicant

CoC Case #

2. Type of Business (Check)
Individual Ownership
Partnership

3. Date Business Was Stablished

Joint Venture
Cooperative
Other
(Explain)

Corporation

Month

Year

FINANCIAL STATEMENT

THE FOLLOWING MUST BE FILLED OUT OR ITS EQUIVALENT ATTACHED

A.

Balance Sheet As Of

,

, Fiscal Year Ends

(Statement must be dated within 90 days of the filing of this application. Omit $.00)

Audited or Unaudited:

Prepared By:

ASSETS

LIABILITIES
$

Cash on Hand and in Banks
* Notes Receivable
* Accounts Receivable (Trade)

$

Accounts Payable for Merchandise
Notes Payable - Payments Due Within One Year
To Banks

$

Less Reserve for Doubtful Accounts
Inventories (How valued - Cost
or Market
$
Finished

For Merchandise

)

To Officers, Directors and Stockholders
To Others

Stock in Process

Mortgages Payable - Payments Due Within One Year

Raw Material
* Other Current Assets

Contracts Payable - Payment Due Within One Year
* Accounts Due Officers or Stockholders

Total Current Assets
Cost

Accounts and Notes Due Affiliates

Depr.

Income Taxes
Withholding and Other Taxes

Land
Buildings

* Other Accruals

Mach. & Equip.
F&F

* Other Current Liabilities
Total Current Liabilities

Autos & Trucks
Net Fixed Assets (Cost Less Depr.)

$

Mortgages Payable - Payments Due After One Year
Contracts Payable - Payments Due After One Year

* Due from Affiliates or Subsidiaries
* Due from Officers, Directors, and Stockholders

SBA Loan - Payments Due After One Year

Life Insurance (Cash Surrender Value)
* Other Assets

* Other Liabilities
$

Total Liabilites
Capital Stock Outstanding

$
$
$

Earned Surplus
Capital Surplus
Total Assets

$

Notes Payable - Payments Due After One Year

Capital Account (If individual or partnership)
$
Total Liabilities and Net Worth
* ITEMIZE ON A SEPARATE SHEET ALL ITEMS MARKED WITH AN ASTERISK.

$

Contingent Liabilities: Accounts or notes receivable discounted or sold with endorsement or guarantee and all other contingent liabilities, including terms
of any leases, should be explained on a separate sheet. Also, describe any pending or imminent litigation, claims against U.S. Government or others.
Give present status.
Ageing
Accounts Receivable
Accounts Payable
Under 30 days

$

$

$

$

30 - 60 days
60 - 90 days
90 - 120 days
Over 120 days
Uncollectible
Totals
Contracts, Notes and Mortgages Payable:
To Whom Payable

Original Amt.

Present
Balance

State Specific Sources for funds to finance this proposed contract:
(Attach letters of credit and/or your personal financial statements, if necessary)

Rate of
Interest

Maturity

Monthly
Payment

Security

COMPARATIVE STATEMENTS OF SALES, PROFIT OR LOSS, ETC. Detailed Profit and Loss Statements Must Be Attached
Fiscal Year Ends (Give Date): MM/DD/YY

to date

If a Corporation, Use This Block:
Net Sales (Gross sales less returns and allowances)
Depreciation
Income Taxes
Compensation of Officers (Included in expenses)
Net Profit (After depreciation and Income Taxes)
Dividends Paid

to date

If a Partnership or Proprietorship, Use This Block:

Net Sales (Gross sales less returns and allowances)
Depreciation
Withdrawals (For Income Taxes)
Personal Withdrawals by Owner or Partners
Net Profit (After depreciation and withdrawals)
B.

MANAGEMENT

Information to be furnished as to each officer, partner, or proprietor of applicant
% of Ownership

Name

PART III

Net Worth Outside of Applicant

CERTIFICATION AND AGREEMENT

In order to comply with the provisions of Section 13, 15 U.S.C 642 of the Small Business Act, the applicant does hereby certify to and agree as follows:
A . In the event SBA issues the Certificate of Competency herein applied for, then for a period of two years from the date upon which such Certificate shall
have been issued, the applicant and his subsidiaries and affiliates agree to refrain from employing, tendering any offer of employment to, or retaining for
professional services, any person who, on such date, or within one year prior thereto, shall have served as an officer, attorney, agent, or employee of
SBA occupying a position or engaging in activities which SBA shall have determined involve discretion with respect to the granting of assistance unde
the above Act
B. The names of all attorneys, accountants, appraisers, engineers, consultants, agents, or other persons engaged by or on behalf of the applicant for the
purpose of expediting this application or obtaining a Certificate of Competency and the fees and/or other compensation paid to any person, are as follows:
Name
Occupation
Address (Include Zip Code)
Compensation

C. The names of any members of the National or District Small Business Advisory Council who have any direct or indirect financial interest whatsoever in
the applicant (such interest to include any direct or indirect financial interest in any other business entity or enterprise which is, in any way, connected
with the undersigned) are to the best of my knowledge, information, and belief as follows:
Name

Address (Include Zip Code)

D. To notify SBA in writing within five (5) days of any changes in items B and C above.
E. The applicant further agrees, in order to insure the continued recognition of the integrity of the SBA Certificate of Competency program if the Certificate
of Competency herein applied for is issued, to permit authorized employees or representatives of SBA access to the applicant's financial, production, or
other business records and to the applicant's facilities at all reasonable times during the performance of the contract described in item 8.
F. That all the statements and all other information set forth in this application and in all exhibits and documents submitted with or in connection with this
application are, to the best of the applicant's information and belief, true and correct and are submitted for the purpose of inducing SBA to grant a
Certificate of Competency to the applicant. To the best knowledge and belief of the applicant, neither the applicant nor any key employee of applicant
(of an individual or if individually owned) nor any officer, partner, or key employee of the applicant (if a corporation, partnership, firm or other business
entity) is now or ever has been a member of any organization, party, association, movement, group, or combination of persons which advocates the
overthrow or destruction of the Government of the United States of America, or of any organization, party, association, movement, group, or
combination of persons which has adopted a policy advocating, approving, or encouraging commissions of acts of force or violence to bring about the
overthrow or destruction of the Government of the United States of America.
Date

,

Signature
NOTE: Corporate applicants must execute application in corporate name, by duly authorized officer, and partnership applicants must execute
application in firm name, together with signature of a general partner.
Section 16 of the Small Business Act, 15 U.S.C. 645, makes it a criminal offense punishable by fine of not more than $5,000 or by imprisonment for not
more than $5,000 or by imprisonment for not more than two (2) years, or both, to make a statement knowing it to be false or make any
misrepresentation to the Small Business Administration for the purpose of influencing in any way the action of the Administration.