0877 VetBiz Vendor Information Pages Verification Program

Form Approved, OMB No. 2900-0675
Respondent Burden: 5 Minutes

VETBIZ VENDOR INFORMATION PAGES VERIFICATION PROGRAM
PRIVACY ACT STATEMENT: The information collected on this form is necessary to meet the eligibility of veteran-owned small business concerns
under Public Law. 109-461, Section 8127 requirements. We will use the information to identify any VA records. Furnishing the information on this
form, including your Social Security Number (No.) and VA File/Claim No. is voluntary; however, if the information is not furnished, VA will not
recognize your small business as veteran-owned or service-disabled veteran-owned. Your obligation to respond is voluntary.
PAPERWORK REDUCTION ACT NOTICE: The collection of information meets the requirement of Public Law 109-461, Section 8127 (f) 4, as
amended by Section 2 of the Paperwork Reduction Act of 1995. This form has been created to provide an efficient way for the Department of Veterans
Affairs to collect and verify veterans and service-disabled veterans in Vendor Information Pages (VIP). We estimate the time to fill out the form to be
about 5 minutes to read the instructions, gather the facts, and answer the questions. VA cannot conduct or sponsor a collection of information unless a
valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed.
PART I - CONSENT TO ACCESS AND VERIFY VETERAN(S) OWNER(S)/VETERAN(S) STOCKHOLDER(S) RECORD(S)

Each veteran owner/veteran stockholder named herein authorizes consent for the Center for Veterans Enterprise (CVE) personnel to access and verify
their records. CVE will match your information with records maintained by VA's Beneficiary Identification Records Locator Subsystem database.
Please see http://www.vip.vetbiz.gov for definitions of veteran, service-disabled veteran, owner, stockholder, Veteran-Owned Small Business (VOSB),
Service-Disabled Veteran-Owned Small Business (SDVOSB), and eligible surviving spouse.
PART II - AFFIRMATION

By electronically signing or FAXing this signed form to (202) 303-3330; I affirm that the articles of incorporation (or other legal documents establishing
the business) are filed with my state and such articles established that at least 51% of the business is owned and controlled (or in the case of stock, at
least 51% of the stock is owned) by veterans or service-disabled veterans, or eligible surviving spouses as stated in Public Law 109-461 Section 8127
(k) (2). I affirm that each of the owners of the business (or in the case of a business with stock, each of the stockholders) is eligible to participate in
Federal contracting and that neither the business nor any of the individual owners appears on the Excluded Parties List at http://epls.gov as identified in
Federal Acquisition Regulation 9.404-3. I further affirm that I have read and understand the language in 13 CFR 125.10 and that the business is
controlled by individuals eligible to participate in the SDVOSB program if I am claiming SDVOSB status.
Any business concern or any veteran determined by VA to have misrepresented the status of that concern as a small business concern owned and
controlled by veterans or as a small business concern owned and controlled by service-disabled veterans shall be debarred from contracting with VA for
a period of five years.
INSTRUCTIONS: This form also applies to eligible surviving spouses. Please provide owner(s) or stockholder(s) names and their pertinent
information below. After completion, print a copy for your records. Hit submit and the form will be sent to the VetBiz Vendor Information Pages
database. DO NOT MAIL copies to VA.
PART III - OWNER/STOCKHOLDER INFORMATION
NAME OF COMPANY

NAME(S) OF EACH
VETERAN OWNER/VETERAN
STOCKHOLDER/SURVIVING SPOUSE

VA FORM
APR 2008

0877

% OF
OWNERSHIP

SERVICE
DISABLED
VETERAN

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

SOCIAL SECURITY NO.
OR VA FILE NO. /
CLAIM NO.

SIGNATURE

DATE
SIGNED

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