1010B - AIT 8(a) Program Application - American Indian - Tribally Ow

OMB Approval No. 3245-0331
Expiration Date: 08/31/07

8(a) Business Development (BD) Program Application
American Indian-Tribally Owned Concern
To Be Completed by SBA
Date Received
CTS Number

Business Information
1.

Name of American Indian Tribe

2.

Address of American Indian Tribe
County

3.

City
State

Zip Code

Business Name of Applicant Concern (include any trade or d.b.a. names)*
*The business must be for profit.

4.

Street Address for Business

City

County
5.

State

Zip Code

Mailing Address (if different from above)

Telephone (Area Code/#):
Fax Number (Area Code/#):

6.

Type of Business:

7.

IRS Employer's ID Number

8.

Primary SIC Code*

Manufacturing
Professional Service
Franchise

Retail Dealer
Non-Professional service
Wholesaler
Number of Employees

Construction
Concession

Date Established
% of Revenues

*The primary Standard Industrial Classification (SIC) code should represent the largest portion of sales
from the most recently completed fiscal year.
9.

PRO-Net User ID#, if applicable:

10.

Is the firm located in a HUBZONE area?

11.

Is the applicant concern certified as a Disadvantaged Business Enterprise (DBE) by a Department of
Transportation recipient?
If yes, identify States(s) and ID number(s):

12.

Do you have any other certification as a disadvantaged business entity, I.E. MBE, DBE, WBE, etc.?
If yes, by which state or localities?

Yes

No

Don't Know

SBA Form 1010B - AIT (8-04)
This form was electronically produced by Elite Federal Forms, Inc.

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Ownership and Management Information
The applicant concern is :

Corporation

Limited Liability Company

Partnership

FOR CORPORATIONS ONLY:
No. of Shares Authorized by Articles of Incorporation:

No. of Shares Issued:

No. of Directors authorized Articles of Incorporation; by-laws; or by amendment to the by-laws:
13.

List Owners, Directors, Officers, Partners and/or Members.

Name and Title:

% Owned

Director

Officer?

Partner or
Member?

U.S.
Citizen?

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

[Circle]
Mr. / Ms.
Mr. / Ms.
Mr. / Ms.
Mr. / Ms.
Mr. / Ms.
Mr. / Ms.
Mr. / Ms.
Mr. / Ms.
Mr. / Ms.
/

No
No
No
No
No
No
No
No
No

No
No
No
No
No
No
No
No
No

No
No
No
No
No
No
No
No
No

FOR ALL CONCERNS:
14.

Does the applicant concern hold, in aggregate, more than a 20 percent equity ownership interest in an existing
8(a) BD concern? Yes ✔ No . If yes, provide the following information: name, title, business name and
addresses, and percentage of ownership. Mark as Attachment 14A.

15.

Does the applicant concern or any nondisadvantaged individual, in aggregated with all immediate family members,
or non-participant concern listed above own, a) more than a 10 percent interest in an existing 8(a) BD concern in
the developmental stage; or b) more than a 20 percent interest in an existing 8(a) BD concern in the transitional
stage? Yes No . If yes, provide the following information: name, title, business name and address of
other 8(a) BD concern, percentage of ownership, and whether the firm is in the developmental or
transitional state. Mark as Attachment 15A.

16.

Does another concern in the same or similar line of business as the applicant firm own at least 10 percent of the
applicant concern? Yes No . If yes, provide the following information: company name, business
address, affiliation with the applicant firm and percentage of ownership. Also, indicate if the firm is a
former 8(a) BD program participant. Mark as Attachment 16A.

17.

Does the applicant concern currently or previously participated in the 8(a) BD program?
Yes No . If yes,
provide the following information: business name of the previous Participant in the 8(a) BD program,
individual name, title, address of previous Participant, dates of participation in the 8(a) BD program and
SBA servicing office of record. Mark as Attachment 17A.

SBA Form 1010B - AIT (8-04)

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No
No
No
No
No
No
No
No
No

18.

Has the applicant concern ever been an owner, stockholder or guarantor for a concern which has received an SBA
loan? Yes No . If yes, provide the following information: business name, date approved, current
status, and SBA office of record. Mark as Attachment 18A.

19.

Does the applicant concern, not including any other firms owned by the American Indian tribe, have any
subsidiaries or affiliates (see 13 CFR 121§103) or is it a subsidiary or affiliate of another concern?
Yes
If yes, provide the following information: name and address of subsidiary and/or affiliate and an
explanation of the existing relationship. Mark as Attachment 19A.

No

20.

Is the applicant concern involved in any present or pending lawsuits?
Yes No . If yes, provide the
following information: details of the suit including current status and a copy of any available documents.
Mark as Attachment 20A.

21.

Has the applicant concern filed for bankruptcy or insolvency proceedings within the past seven years?
If yes, provide details and a copy of the bankruptcy court's final dispensation. Mark as Attachment
21A.

22.

Is the applicant concern debarred, suspended, voluntarily excluded or otherwise ineligible for procurement or
Yes
No . If yes,
non-procurement purposes from any department or agency of the Federal Government?
please provide a detailed statement explaining the circumstances of the action with any relevant
documentation. Mark as Attachment 22A.

23.

Does the Tribe own the applicant concern directly or through a wholly-owned subsidiary?
wholly owned subsidiary, provide the name and address of the wholly owned subsidiary.

No

Yes

.

No

.

If through a

When submitting your application, please provide the original application, including all original SBA and IRS Forms, and
a copy of the items listed in the "Checklist of Required 8(a) BD Program Application Documents." All complete
applications will be processed; incomplete applications will be returned.

SBA Form 1010B - AIT (8-04)

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FOR CORPORATIONS ONLY:
Corporate Seal (if required by state):

By:

President's Signature

Date

Attest By:

Corporate Secretary's Signature

Date

FOR ALL CONCERNS (corporations, partnerships, and limited liability companies):
All officers, directors, partners, members and all owners of more than 10% must sign below.
By:

Date

By:

Date

By:

Date

By:

Date

By:

Date

By:

Date

By:

Date

By:

Date
PLEASE NOTE: The estimated burden for completing this form is 5 Hours per response. You are not required
to respond to any collection of information unless it displays a currently valid OMB approval number.
Comments on the burden should be sent to U.S. Small Business Administration, Chief, AIB, 409 3rd St., S.W.,
Washington D.C. 20416 and Desk Officer for the Small Business Administration, Officer of Management and
Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503. OMB Approval (3245-0015). PLEASE DO NOT
SEND FORMS TO OMB.

SBA Form 1010B - AIT (8-04)

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CHECKLIST OF REQUIRED 8(A) BD PROGRAM APPLICATION DOCUMENTS FOR
AMERICAN INDIAN TRIBE-OWNED CONCERN
Please provide all of the following documents in the order that they are listed and check if attached. NOTE "N/A" IF
NOT APPLICABLE.
TRIBAL ELIGIBILITY
In order to qualify a concern which it owns and controls for participation in the 8(a) BD program, an Indian tribe must
establish its own economic disadvantaged status under 13 CFR 124.109 (b)(2). Thereafter, it need not reestablish such
status in order to have other businesses that it owns certified for 8(a) BD program participation.
If the tribe has not previously established its economic disadvantaged status, provide the following information for
the tribe:
•
•
•
•
•
•

The number of tribal members.
The present tribal unemployment rate.
The per capita income of tribal members, excluding judgment awards.
The percentage of the local Indian population below the poverty level.
The tribe's access to capital markets.
The tribe's assets as disclosed in the current tribal financial statement, including those which are encumbered
or held in trust; the status of assets encumbered or in trust must be clearly delineated.

Evidence of recognition as a tribe eligible for the special programs and services provided by the United States or
by its state of residence.
BUSINESS ELIGIBILITY
For all concerns:
Copy of Articles of Incorporation as filed with the organizing or chartering authority, or similar documents
needed to establish and govern a non-corporate entity (i.e. partnership or operating agreement). The Articles,
Partnership Agreement or Operating Agreement, must contain express sovereign immunity waiver language, or a
"sue and be sued" clause which designated U.S. Federal Courts to be among the courts of competent jurisdiction
for all matters relation to SBA's programs.
SBA Form 912, Statement of Personal History - Provide for all directors, officers, members of the governing
board or business committee of the concern, and individuals owning more than 10%, and any other person,
including a hired manager, who has authority to speak for and commit the concern. (Form FD-258, Fingerprint
Card, required for affirmative answers to questions 6, 7, and 8).
If applicable, signed copies of individual Federal income tax returns filed for the past two years, including all W2 forms and all schedules and attachments. Provide for all individuals owning more than 10%. Please provide
signed and dated IRS Form 4506, Request for Copy or Transcript of Tax Form.
A resume of the education, technical training and business and employment experience, including employer's
name, dates of employment, nature of employment for general managers, officers, and key employees (please
account for all time).
If members of the management team, business committee members, officers, and directors are currently employed
outside the applicant concern, provide information on this employment and evidence that the activity does not
conflict with the day-to-day management of the applicant concern. Please indicate the number of hours per week
and the normal working hours of this outside employment.
SBA Form 1010B - AIT (8-04)

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For corporations only:
Copy of By-Laws, including all amendments, as filed with the organizing or chartering authority.
Copy of all governing documents, such as the tribe's constitution or business charter.
Copies of all minutes of shareholders meeting electing board of directors and minutes of last shareholders
meeting.
Copies of all minutes of board of directors meetings and all resolutions of the board of directors, including a copy
of the resolution to seek 8(a) BD certification.
Copies of all stock certificates (front and back) and stock register.
Copy of the current Certificate of Good Standing from the Tribe.
Copy of the Foreign Status Certificates from the state.
Other business eligibility documents - for all concerns:
Copies of buy/sell agreements, conditions precedent, conditions subsequent, executory agreements, voting trusts,
shareholder agreements or other similar arrangements which may impact the unconditional ownership of the
disadvantaged individuals.
Current schedule of business insurance (e.g. comprehensive, liability, worker's compensation, etc.).
Copies of franchise or trust agreements.
A brief description and history of the business.
Current business license (city, county, or state, as required by law).
Copies of any special licenses (e.g. public accountancy, engineering, architectural, contractor, etc.).
A copy of any distributorship, licensing or franchise agreement.
Copy of the current lease agreement(s) and/or proof of ownership for all business facilities.
Copy of current lease agreement(s) for equipment, if applicable.
Copies of all loan agreements, including lines of credit.
Copies of signature cards for all business bank accounts.
Copies of all management and joint venture agreements, indemnity agreements and consulting agreements,
including agreements for assistance in completing this 8(a) BD application.
Provide a list of contracts held with the Federal government. Include award date, agency name, description of
work and dollar value.
SBA Form 1623, Certification Regarding Debarment, Suspension, and Other Responsibility Matters.
A list of all affiliates and subsidiaries. The list should identify the name and address of the affiliate and/or
subsidiary, the type of business, and the names of the affiliate/subsidiary's owners, directors and officers.
If bonding is required by your industry, such as construction, a statement of the bonding limit from a surety
company, specifying single job limit and aggregate limit.
SBA Form 1010B-AIT (8-04)

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FINANCIAL DATA
If there are tax liens, unsatisfied judgments, or lawsuits involving the concern or individuals involved in the
applicant concern as directors, general managers, and officers, evidence of repayment arrangement, proof of
compliance with repayment arrangements, and latest status of lawsuits are required.
A current balance sheet and profit and loss statement, including an aging of accounts for the concern no older than
90 days from the filing date of this application, signed, certified and dated by the concern's highest managing
individual, if a corporation, usually CEO.
A balance sheet and profit and loss statement for each of the three preceding fiscal year-end periods, signed,
certified and dated by the concern's highest individual managing individual, if a corporation, usually CEO.
Signed copies of business Federal tax returns, including all schedules, filed for the past three years, if applicable.
Signed copies of financial statements and Federal tax returns of any subsidiaries or affiliates for each of the three
preceding fiscal year-end periods.

OTHER REQUIREMENTS
Provide signature on the attached "Authorization, Certification and Notices."
"Representatives and Fees." If representatives were used, please complete the attached form.
Length of Time in Business. See below for additional requirements for applicants that have not been in business
for two full years.
Length of Time in Business Requirement
Eligibility criteria requires that an applicant concern must demonstrate that it has been in business in the primary
industry classification in which it seeks 8(a) BD certification for two full years prior to the date of its 8(a) BD
application by submitting income tax returns showing revenues, for each of the two previous years. If the
concern does not meet this requirement, the concern must demonstrate potential for success. In determining
potential for success, SBA will look at a number of factors including, but not limited to: [13 C.F.R. 124 109(c)]
A.

Technical and managerial experience and competency of the individual(s) who manage and control the daily
operations of the concern;

B.

The financial capacity of the concern; and

C.

The concern's record of performance on any previous Federal or private sector contracts its primary industry
classification.

SBA Form 1010B-AIT (8-04)

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AUTHORIZATION, CERTIFICATION AND NOTICES
Read the following paragraphs carefully. Your signature on the 8(a) BD Business Eligibility Statement indicates
acceptance and understanding of these conditions.
A.

Authority to Collect Personal Information: The U.S. Small Business Administration (SBA) is authorized to
determine eligibility for the 8(a) BD Program under Section 124 of Title 13 of the U.S. Code of Federal
Regulations. The information submitted on SBA Form 1010A and 1010B is used to determine personal and
business eligibility for the 8(a) BD Program. Information submitted may be given to Federal, State and local
agencies for law enforcement purposes.

B.

Incomplete Applications: If the application is not complete, SBA will return the application to you along with a
listing of missing or incomplete documentation. You may then reapply when the application is complete.

C.

Disclosure of Information: All information submitted in connection with this application may be disclosed to
Federal procurement agencies considering furnishing contracts to this business.

D.

Payment to SBA Employees: Payment of any fee or gratuity to SBA employees is illegal and will subject the
parties of such a transaction to prosecution.

E.

Access to records: Applicant agrees to allow SBA access and the right to examine corporate records including, but
not limited to, books, documents, papers and other material considered by SBA to be necessary.

F.

True and Complete Statements: By signing this form, you are certifying that all information in your 8(a) BD
application, including exhibits, is true and complete to the best of your knowledge and is submitted for
consideration of 8(a) BD Program eligibility.

FOR CORPORATIONS ONLY:
Corporate Seal (if required by state):
By:

President's Signature

Date:

Attest By:

Corporate Secretary's Signature

Date:

FOR PARTNERSHIPS ONLY:
All partners must sign:
Partner:
Partner:
Partner:
Partner:
Partner:
Partner:

Date:
Date:
Date:
Date:
Date:
Date:

SBA Form 1010B-AIT (8-04)

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FOR LIMITED LIABILITY COMPANIES ONLY:
All members must sign:
Member:

Date:

Member:

Date:

Member:

Date:

Member:

Date:

Under Title 18 U.S.C. Section 1001 and Title 15 U.S.C. Section 645, any person who misrepresents a firm's status
as an 8(a) business concern, or makes any other false statement in order to influence the certification process in any
way, or to obtain a contract awarded under the preference programs established pursuant to section 8(a), 8(d), 9, or
15 of the Small Business Act, or any other prevision of Federal Law that references Section 8(a) for a definition of
program eligibility shall be:
1.

Subject to fines and imprisonment of up to 5 years, or both, as stated in Title 18 U.S.C. Section 1001; and
subject to fines of up to $500,000 and imprisonment of up to 10 years, or both, as stated in Title 15 U.S.C.
Section 645.

2.

Subject to civil and administrative remedies, including suspension and debarment.

3.

Ineligible for participation in programs conducted under the authority of the Small Business Act.

SBA Form 1010B-AIT (8-04)

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REPRESENTATIVE AND FEES

It is not necessary for you to retain representation to assist in the preparation and presentation of this or any other 8(a)
application. However, if you do retain such representation, SBA will determine the reasonableness of fees or other
compensation for services actually performed by representatives on your behalf.
List the names of attorneys, accountants, appraisers, agents or other representatives who assisted in the preparation or
filing of the application. Indicate the amount of fees, bonuses, commissions or expenses paid or due. SBA reserves the
right to require, at a later date, a full itemization by representatives of actual services rendered. Attach additional sheet(s),
if necessary.

NAME AND OCCUPATION
OF REPRESENTATIVE

DESCRIPTION OF SERVICES

TOTAL FEES
PAID
DUE

The compensation received by an agent or representative of an 8(a) BD applicant for assisting the applicant in obtaining
8(a) BD certification must be reasonable in light of the services performed by the agent or representative.
The fee charged by any agent or representative of an 8(a) BD applicant for assisting the applicant in obtaining 8(a) BD
certification cannot be contingent upon the applicant receiving certification.
Signature(s) of Representative(s)

Date

Signature of Applicant

Date

SBA Form 1010B-AIT (8-04)

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