HUBZone 3AGCOP HUBZone Program Certification for Small Agricultural Coo

OMB Approval No. 3245-0320

Expiration Date: 4/30/2010

HUBZone Program Certification for Applicants Owned by Small Agricultural Cooperatives

Please read carefully the following certification statements and have the authorized officer or officers of the applicant sign and date the form. The U.S. Small Business Administration (SBA) relies on the information in the applicant’s online submission, this form and any documents or supplemental information submitted in connection with this application to determine whether the applicant qualifies as a HUBZone small business concern (SBC). The definitions for the terms used in this certification and throughout this application are set forth in the Small Business Act (15 U.S.C. § 632), SBA regulations (13 C.F.R. Part 126), and also any statutory and regulatory provisions referenced in those authorities. In addition, please note that SBA may request further clarification or supporting documentation in order to assist in the verification of any of the information provided and that each person signing this certification may be prosecuted if they have provided false information. Any action taken with respect to this application does not affect the Government’s right to pursue criminal, civil or administrative remedies for incorrect or incomplete information given on the application form, even if correct information has been included in other materials submitted to SBA.

The undersigned has reviewed, verified and certifies that (all boxes must be checked):

□ The applicant meets SBA ownership requirements because (check the applicable line):

__ The applicant is a small agricultural cooperative organized or incorporated in the United States.

__ The applicant is a small business concern wholly owned by one or more small agricultural cooperatives organized or incorporated in the United States.
__ The applicant is a small business concern owned in part by one or more small agricultural cooperatives organized or incorporated in the United States, provided that all other owners are small business concerns or United States citizens.

□ The applicant meets the size standard corresponding to its primary industry classification as defined in 13 C.F.R. Part 121.

□ The applicant’s principal office is located in a HUBZone.

□ At least 35% of the applicant's employees reside in a HUBZone. When determining the percentage of employees that reside in a HUBZone, if the percentage results in a fraction, the applicant has rounded up to the nearest whole number;

□ The applicant represents that it will make good faith efforts to “attempt to maintain” (see 13 C.F.R. § 126.103) having 35% of its employees reside in a HUBZone during the performance of any HUBZone contract it receives.

□ The applicant represents that it will ensure that it will comply with certain contract performance requirements in connection with contracts awarded to it as a qualified HUBZone SBC, as set forth in 13 C.F.R. § 126.700 and/or the nonmanufacturer rule as set forth in 13 C.F.R. § 126.601(e).

□ The applicant has not been declined or decertified from the HUBZone Program within one year of the date of this application.

□ All the statements and information provided in the applicant’s online application, this form and any attachments are true, accurate and complete. If assistance was obtained in completing this form and the supporting documentation, I have personally reviewed the information and it is true and accurate. I understand that these statements are made for the purpose of determining eligibility and continuing eligibility in the HUBZone Program. In addition, the applicant will immediately notify the SBA of any material change which could affect the applicant’s HUBZone SBC eligibility.

□ I understand that the information submitted may be given to Federal, State and local agencies for determining violations of law and other purposes. The certifications in this document are continuing in nature. Each HUBZone prime contract or subcontract for which the applicant submits an offer/quote or receives an award while a HUBZone SBC constitutes a restatement and reaffirmation of these certifications. I understand that the applicant may not misrepresent its status as a HUBZone SBC to: 1) obtain a contract under the Small Business Act; or 2) obtain any benefit under a provision of Federal law that references the HUBZone Program for a definition of program eligibility.

□ I am an officer of the applicant authorized to represent the applicant and sign this certification on its behalf.

Warning: By signing this certification you are representing on your own behalf, and on behalf of the applicant, that the information provided in this certification, the application and any document or supplemental information submitted in connection with this application, is true and correct as of the date set forth opposite your signature. Any intentional or negligent misrepresentation of the information contained in this certification may result in criminal, civil or administrative sanctions including, but not limited to: 1) fines of up to $500,000, and imprisonment of up to 10 years, or both, as set forth in 15 U.S.C. § 645 and 18 U.S.C. § 1001, as well as any other applicable criminal laws; 2) treble damages and civil penalties under the False Claims Act; 3) double damages and civil penalties under the Program Fraud Civil Remedies Act; 4) suspension and/or debarment from all Federal procurement and nonprocurement transactions; and 5) program termination.

Signature	Date__/__/__	Signature	Date __/_/__
Print Name (First, Middle, Last)		Print Name (First, Middle, Last)
Title		Title
Business Name

Note: This certification must be verified in front of a notary. In addition, if the applicant is a corporation, please have the Corporate Secretary witness these signatures and affix the corporate seal, if required by state statute or corporate charter.

VERIFICATION ON OATH OR AFFIRMATION

State of ___________________________________________

(County) of ________________________________________

Signed and sworn to (or affirmed) before me on the__________ day of ___________ 20__,

by ____________________________________________________________________

(Seal, if any)

_______________________

Signature of notarial officer

[My commission expires: ____________]

CORPORATE CERTIFICATE

I, ________, certify that I am the Secretary of XYZ Corporation; that ___________, who signed this Agreement for this corporation, was then ___________ of this corporation; and that this Agreement was duly signed for and on behalf of this corporation by authority of its governing body and within the scope of its corporate powers. Witness my hand and the seal of this corporation this day of ___________ 20_____________

By_____________________________________________

HUBZone Program Certification

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