1010B-ANC 8(a) Program Application - Alaskan Native Corporation-Ow

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

8(a) Business Development (BD) Program Application
Alaskan Native Corporation-Owned Concern
To Be Completed by SBA
Date Received
CTS Number

Business Information
1.

Name of Parent Alaskan Native Corporation (ANC)

2.

Address of Parent ANC

City

County
3.

State

Zip Code

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

4.

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

5.

Street Address for Business

City

County
6.

State

Zip Code

Mailing Address (if different from above)

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

7.

Type of Business:

8.

IRS Employer's ID Number

9.

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.
10.

PRO-Net User ID#, if applicable:

11.

Is the firm located in a HUBZONE area?

12.

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):

13.

Do you have any other certification as a disadvantaged business entity, I.E. MBE, DBE, WBE, etc.?

Yes

No

Don't Know

If yes, by which state or localities?
SBA Form 1010B-ANC (8-04)
This form was electronically produced by Elite Federal Forms, Inc.

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Ownership and Management Information
The applicant concern is :

14.

Corporation

Partnership

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

Limited Liability Company

No. of Shares Issued:

No. of Directors authorized Articles of Incorporation; by-laws; or by amendment to the by-laws:
List Owners, Directors, Officers, Partners and/or Members.

15.

Name and Title:
[Circle]
Mr. / Ms.
Mr. / Ms.
Mr. / Ms.
Mr. / Ms.
Mr. / Ms.
Mr. / Ms.

% 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

No
No
No
No
No
No

No
No
No
No
No
No

No
No
No
No
No
No

FOR ALL CONCERNS:
16.

Does the applicant concern hold, in aggregate, more than a 20 percent equity ownership interest in an existing
No . If yes, provide the following information: name, title, business name and
addresses, and percentage of ownership. Mark as Attachment 16A.
8(a) BD concern? Yes

17.

Does the applicant concern or any nondisadvantaged individual, in aggregate 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 stage. Mark as Attachment 17A.

18.

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
Addresses, 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 18A.

19.

Has 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 19A.

20.

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: name, business name, and date approved,
current status, and SBA office of record. Mark as Attachment 20A.

SBA Form 1010B-ANC (8-04)

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No
No
No
No
No
No

21.

Does the applicant concern, not including any other firms owned by the ANC, have any subsidiaries or
Yes No . If yes,
affiliates (see 13 CFR 121 § 103) or is it a subsidiary or affiliate of another concern?
provide the following information: name and address of subsidiary and/or affiliate and an explanation of
the existing relationship. Mark as Attachment 21A.

22.

Is the applicant concern, any person listed above, or another person, such as key employees with significant
authority over the concern, involved in any present or pending lawsuits? Yes No . If yes, provide the
following information: name of the individual, details of the suit, including current status, and provide a
copy of any available documents. Mark as Attachment 22A.

23.

Has the applicant concern filed for bankruptcy or insolvency proceedings within the past seven years?
Yes
. If yes, provide-details and a copy of the bankruptcy court's final dispensation. Mark as Attachment
23A.

24.

Is the applicant concern, any director, officer, partner, member, or any owner of more than 10% (or their
spouse), or any immediate family member debarred, suspended, voluntarily excluded or otherwise ineligible for
Yes
procurement or non-procurement purposes from any department or agency of the Federal Government?
No . If yes, please provide a list of such individuals identifying their names and positions with said
organization. Mark as Attachment 24A.

25.

Does the ANC or wholly-owned subsidiary of the ANC own 51% or more of another firm which either at the
time of application or within the previous two years, has been operating in the 8(a) program?
Yes No . If yes,
identify the firm(s) and such firm's primary SIC code. Mark as Attachment 25A.

No

SBA Form 1010B-ANC (8-04)

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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.

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:
By:
By:
By:
By:
By:
By:
By:

Date
Date
Date
Date
Date
Date
Date
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.

The questions on the attached form were abstracted from the previous SBA Form 1010B OMB #3245-0015.

SBA Form 1010B-ANC (8-04)

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CHECKLIST OF REQUIRED 8(a) BD PROGRAM APPLICATION DOCUMENTS FOR
ALASKAN NATIVE CORPORATION-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.
PERSONAL ELIGIBILITY
SBA Form 413, Personal Financial Statement - Provide for all individuals claiming disadvantaged status
and his/her spouse, splitting all assets and liabilities as appropriate.
If applicable, signed copies of individual Federal income tax returns filed for the past two years,
including all W-2 forms and all schedules and attachments. Provide for all individuals owning more than
10% and all individuals claiming disadvantaged status. 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 and nature of employment, for general managers, officers, and
key employees (please account for all time).
Documentation which demonstrates the legal status of the ANC.

BUSINESS ELIGIBILITY
For corporations only:
Copy of Articles of Incorporation as filed with the state.
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 state where concern is incorporated. If concern
conducts business in a state other than where it was incorporated, a copy of the filing as a Foreign
Corporation and a current Certificate of Good Standing from that state are required as well.
For partnerships only:
Copy of Partnership Agreement.

SBA Form 1010B-ANC (8-04)

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BUSINESS ELIGIBILITY (continued)
For limited liability companies only:
Copy of Operating Agreement.
Copy of Articles of Organization as filed with the state.
Other business eligibility documents - for all concerns:
Copies of buy/sell agreement, conditions precedent, conditions subsequent, executory agreements,
voting trusts, shareholder agreements or other similar arrangements which may impact the unconditional
ownership of the disadvantaged individuals.
Copies of current business insurance declaration pages (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.).
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-ANC (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 as evidenced by tax returns reporting revenue.
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-ANC (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
persoanl 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 applicaton is
complete.

C.

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

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:

Date:
Date:
Date:
Date:
Date:

SBA Form 1010B-ANC (8-04)

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

Date:
Date:
Date:
Date:
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-ANC (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-ANC (8-04)

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