Form SBA FORM 355 SBA FORM 355 Information for Small Business Size Determination

OMB Approval No: 3245-0101

Expiration Date: 10/31/2009

INFORMATION FOR SMALL BUSINESS SIZEDETERMINATION

General Instructions

CAREFULLY READ ALL OF THESE INSTRUCTIONS AND THE SBA SIZE REGULATIONS BEFORE COMPLETING THIS FORM (incomplete information may affect the size determination)

1. The information provided in this form will be used by the Small Business Administration (SBA) for a size determination of a business seeking assistance available to small businesses under any program administered by this Agency, except for its Small Business Investment Companies (SBIC) Program which uses SBA Form 480, or at the request of another Federal agency for purposes of its small business program. A small business is a concern which is independently owned and operated, not dominant in its field of operation, and does not exceed the size standard applicable to the procurement or program for which the business is applying.

2. SBA is authorized to make size determinations pursuant to the Small Business Act, 15 USC 637(a) and regulations thereunder for the purpose of deciding small business protests and to determine eligibility for program assistance. SBA's size regulations are found generally at Title 13 Code of Federal Regulations Part 121. SBA may, at its discretion, request additional information not specifically identified on this form.

3. Upon request of SBA, one copy of SBA Form 355, with additional sheets attached as needed, must be returned to the SBA Government Contracting Area Office closest to the business' principal location. The person signing this form must be authorized to do so. Non-employee representatives of the business, such as an attorney or accountant, must provide a letter authorizing them to represent the firm. The information requested must be complete. Failure to supply complete information may cause delays in making a size determination or lead to adverse inferences that the business is other than small.

4. All affiliates of the business, whether acknowledged or not, and whether foreign or domestic, must be disclosed. SBA's criteria for defining affiliates should be carefully reviewed. In 13 CFR § 121.103, SBA identifies various forms of affiliation. You can find this regulation on the size standards website at http://www.sba.gov/size. The website also provides some examples of affiliation under “Guide to Size Standards.” Completion of Parts IV and V of this form does not constitute an admission or confirmation of affiliation.

5. Where the applicable size standard involves "numbers of employees," a business' average number of employees on payroll for the 12 completed calendar months preceding the date of application or offer is examined, including all employees who are hired on a full-time, part‑time, temporary or other basis, including employees of domestic and foreign affiliates. See 13 CFR § 121.106 of SBA's regulations. For purposes of Economic Injury Disaster Loans, the average number of employees for the 12 months preceding the disaster is examined.

6. Where applicable size standards involve "average annual receipts," a business' annual receipts means total income (or gross income in the case of a sole proprietorship) plus cost of goods sold, as these terms are defined and reported on the business's Federal Income Tax Return. See 13 CFR § 121.104 of SBA's regulations.

7. SBA must determine the primary industry activity or the North American Industry Classification System (NAICS) code of a business for certain assistance programs, as part of its size determination. For this, SBA considers various criteria, such as revenues from the business and its affiliates, employees of the business and its affiliates and costs of doing business among the different industries in which the business operations occurred for the most recently completed fiscal year. See 13 CFR§ 121.107.

8. For purposes of this form, SBA considers principals of the business those persons or affiliated businesses that have a 10 percent or more interest in the business or its stock. In cases where no individual or affiliated business owns at least 10 percent interest, the five largest interest holders and their percentages of interest must be listed. Additionally, the principal officers and their interest in the business must be listed.

SBA FORM 355 (9-09) previous editions are obsolete

9. Where certain financial assistance programs are involved, the business must include the county in which it operates, and state whether government funds (loans or grants) to be received will be used in a Labor Surplus Area. Labor Surplus Areas are defined in the Department of Labor publications "Area Trends in Employment and Unemployment." See 13 CFR § 121.301(e).

10. Certain industries require special information. Please review the Size Standards Table and any applicable footnote in 13 CFR § 121.201. Some of the industries noted are:

Depository Institutions (NAICS codes 522110 & 522120) Real Estate Agents and Brokers (NAICS code 531210)

Tire Manufacturing (except Retreading) (NAICS code 326211) Office Administrative Services (NAICS code 561110)

Dredging and Surface Cleanup Activities (NAICS code 237990) Travel Agencies (NAICS code 561510)

Petroleum Refining (NAICS code 324110) Fruit and Vegetable Canning (NAICS code 311421)

Advertising (NAICS code 541810) Electric Services (NAICS codes 211111, 221112, 221113, 221121, 221122)

CRIMINAL PENALTIES FOR FALSE STATEMENTS:

Any intentional or negligent misrepresentation of the information contained in this form 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; and 4) suspension and/or debarment from all Federal procurement and nonprocurement transactions.

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CERTIFICATION:

I hereby certify that (1) I have made diligent efforts to obtain all information needed to complete this form; (2) I have reviewed all of the responses to the questions in this form and all exhibits and attachments submitted with this form; and (3) all information, exhibits, and attachments are true and correct to the best of my knowledge. I understand that the U.S. Small Business Administration (SBA) is relying on this information in order to make a size determination so that my business may receive assistance under the laws and regulations administered by SBA or so that my business can obtain a Federal contract.

_____________________________________________________

(name of sole proprietorship, partnership, limited liability company

or corporation)

By:__________________________________________________

Signature

Name and Title:________________________________________

Date of signing: ________________________________________

PLEASE NOTE: The estimated burden hours for the completion of this form is 4 hours per response. You are not required to respond to this information collection if a valid OMB approval number is not displayed. If you have any questions or comment concerning this estimate or any other aspect of this information collection, please contact the U.S. Small Business Administration, Chief, Administrative Information Branch, 409 3^rd Street, S.W., Washington, DC 20416 and/or Office of Management and Budget, Clearance Officer, Paperwork Reduction Project (3245-0101), Washington, DC 20503. PLEASE DO NOT SEND FORMS TO OMB.

SBA FORM 355 9-09 previous editions are obsolete

OMB Approval No: 3245-0101

Expiration Date: 10/31/2009

INFORMATION FOR SMALL BUSINESS SIZE DETERMINATION

____________________________________________________________________________________________________________________

Part I. Information relating to business only:

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1a. Name and address of business 1b. Name and title of person authorized to provide

(Street, City, State & Zip Code) information:

Telephone No.:

______________________________________

Fax No.: ______________________________________

E-mail address: ______________________________________

DUNS No.:

____________________________________________________________________________________________________________________

1c. Located in ______________________________county/city 1d. Size status determination requested for

If determination is needed for a financial assistance program receiving:

other than surety bond guarantee, will assistance funds be Surety Bond _____ HUBZONE _____

used in a labor surplus area? Business Loan _____ Section 8(a) eligibility __

Econ. Injury Disaster Loan _____

yes _____ no _____ Sec. 8(a) Contract _____ Cert. of Competency

Gov't. Prime Contract _____ Subcontract ____

Women Owned Status _____

Service-Disabled Veteran Owned _____

Other (Specify) _______________________

____________________________________________________________________________________________________________________

1e. Date business was established or incorporated: ________________________________________________________________________

Note: If business is a corporation, a copy of its latest annual report to stockholders, bylaws, and articles of incorporation must be attached to this form. If business is a partnership, a copy of its partnership agreement must be attached. If business is a limited liability company, a copy of its articles of organization and operating agreement must be attached.

____________________________________________________________________________________________________________________

1f. Primary business activity by 1g. Has business previously been the subject North American Industry Classification formal SBA size determination? Yes ___ No ___

System (NAICS) code _______________ If yes, then what SBA Government Contracting

Area Office? _______________________________

When? (Date) ______________________________

Name of Federal Contracting Agency: ___________

Name and telephone number of contracting

Officer: ___________________________________

____________________________________________________________________________________________________________________

2. Business' major products or services:

Share of sales or receipts for most recently completed fiscal year:

Products/services	NAICS codes	Fiscal year % of sales	Dollar value

____________________________________________________________________________________________________________________

3. Does business issue or operate under a franchise, license, or other contractual agreement with another concern?

yes _____ no _____ If yes, attach a copy of agreement.

____________________________________________________________________________________________________________________

4. Name and address of owners, partners, principal stockholders or members of business organization. Please denote the type of partners.

Name and address	% of voting stock or kinds of interest

5. Name and address of all officers of business:

Name and address	Position held

6. Name and address of members of the Board of Directors of business (if a corporation):

Name	Address

____________________________________________________________________________________________________________________

7a. Has business made any stock options available? ____ yes ____ no. If yes, identify person or concern holding options.

7b. Has business pledged any stock as collateral? ____ yes ____ no. If yes, provide details of arrangement.

7c. Is any of the business’ stock held by a trust or voting trust? ____ yes ____ no. If yes, provide details of arrangement.

____________________________________________________________________________________________________________________

8. Are there any pending mergers or sale of business by stock or assets? ____ yes ____ no. If yes, submit details and copies of relevant documents.

____________________________________________________________________________________________________________________

9a. Is the business or any person listed in questions 4, 5, or 6 (i.e., the owner, partner, director, officer, member, employee, or principal stockholder) in another business? ____ yes ____ no. If yes, complete section 9b below.

____________________________________________________________________________________________________________________

9b.

Name of persons	Names of businesses and addresses	Position held	% interest of persons in business

Part II. Information relating to employee-based size standards.

____________________________________________________________________________________________________________________

Number of Employees (NOTE: Number of employees includes full-time, part-time, temporary, seasonal or periodic employees).

10a. How many employees does the business currently have? .

10b. What has been the business' average number of employees on payroll for the preceding twelve months? __________

Part III. Information relating to revenue-based size standards.

____________________________________________________________________________________________________________________

11. What is the business' federal year ending tax date?

____________________________________________________________________________________________________________________

12. (a) Gross sales or receipts of the business for each of its most recently completed three fiscal years as of the date of the application or offer. For the purpose of Economic Injury Disaster Loans, show the sales of the three fiscal years completed prior to the disaster.

Year: $____________________________________

Year: $____________________________________

Year: $____________________________________

Total: $____________________________________

____________________________________________________________________________________________________________________

Part IV: Information about affiliates, including those identified in Part I item 9b.

13. Affiliates (domestic and foreign)

General Instruction #4 above provides guidance on determining whether a company is considered an “affiliate” of business and whether information about the affiliate must be reported. If there are questions about whether a company should be considered an affiliate, please contact the SBA Area Government Contracting Office.

Note: All documentary materials about affiliates, including recorded documents, operating documents, financial and tax information are to be submitted with this form

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13a.Acknowledged affiliates

Name and address of affiliates	% of ownership interests in affiliates	% of ownership interests in business	NAICS code of major product or service

13 b. Name and addresses of owners, partners, directors, members, and principal stockholders of each business in 13a.

Name and address	Position held	% interest in business

13c. Number of employees currently employed by each business listed in 13a. (Attach separate sheet if needed)

____________________________________________________________________________________________________________________

13d. Gross sales or receipts of each business listed in 13a for each of the most recently completed three fiscal years as of the date of size determination or offer. For the purpose of Economic Injury Disaster Loans, show the sales for the three fiscal years completed prior to the disaster.

Business:	Business:	Business:
$:	$:	$:
$:	$:	$:
$:	$:	$:
Total:	Total:	Total:

14a. Are there any persons listed in question 13b who are also owners, partners, directors, members or principal stockholders in another company? ____ yes ____ no. If yes, complete section 14b below.

____________________________________________________________________________________________________________________

14b.

Name of person	Name of company and address	Position held	% interest in company held

Part V. Information about alleged, acknowledged or possible affiliates of business.

Note: Complete questions 15 through 22 in all cases where you are contesting alleged affiliation. The term “contesting” means the firm filling out this form does not agree with the allegation that it is affiliated with a firm noted in the size protest. If you are not contesting an alleged affiliation, complete questions 15 through 22 only if requested by SBA. For size determination pertaining to procurement programs. questions 23-29 must be completed. Attach a separate explanation for any question answered "yes".

15. Have any owners, officers, directors, key employees or supervisors of business ever been employed by or performed similar work for any alleged, acknowledged or possible affiliates? _____ yes ____ no

____________________________________________________________________________________________________________________

16. At the time of bid opening or request for assistance or at the present, have any services been performed by business for any alleged, or acknowledged affiliates or vice versa? ____ yes ____ no

____________________________________________________________________________________________________________________

17. At the time of bid opening or request for assistance, did business share any facilities, equipment, or personnel with any of the alleged, or acknowledged affiliates? (vehicles, telephone lines, office space, receptionist, etc.) ?

____ yes ____ no

____________________________________________________________________________________________________________________

18. In preparing the subject bid or request for assistance, was any assistance provided by an alleged or acknowledged affiliate?

____yes ____ no

____________________________________________________________________________________________________________________

19. Have there been or are there any current financial obligations between business and the alleged or acknowledged affiliates?

____ yes ____ no

____________________________________________________________________________________________________________________

20. Are there any individuals who have signed or are expected to sign documents to facilitate the ability of business to receive indemnifications or credit guarantees, who are not owners, officers, directors, employees, partners, members or principal stockholders? _____ yes ____ no

____________________________________________________________________________________________________________________

21. Does any family member of an owner, partner, officer, director, member or principal stockholder of business have an ownership interest in any of the alleged or acknowledged affiliates? ____yes ____ no

____________________________________________________________________________________________________________________

22. Has SBA ever determined the business to be affiliated with any of the alleged or acknowledged affiliates, or to the best of your knowledge, determined any of the alleged or acknowledged affiliates to be affiliated with each other?

____ yes ____ no

If yes, attach a copy of the determination(s) if available, or describe the determination(s) made by SBA.

____________________________________________________________________________________________________________________

23. Will any of the alleged or acknowledged affiliates, or any of their principals, provide an indemnity or guaranty to a surety to facilitate a contract award to business? ____ yes ____ no

Has such an indemnity or guaranty been provided within the past two years? ____ yes ____ no

____________________________________________________________________________________________________________________

24. Have any of the alleged or acknowledged affiliates assisted in arranging for any of the subcontractors needed for performance of this contract or any contract awarded to business within the last two years? ____ yes ____ no

____________________________________________________________________________________________________________________

25. Have there been or are there any actual or proposed subcontracts between business and any of the alleged or acknowledged affiliates? ___ yes ____ no

____________________________________________________________________________________________________________________

26. Were there any discussions as to specific terms or conditions relating to the subject contract which took place between business and any of the alleged or acknowledged affiliates prior to bid opening? ____ yes ____ no

____________________________________________________________________________________________________________________

27. Will any of the alleged or acknowledged affiliates perform more than 25 percent of this contract? ____ yes ____ no

____________________________________________________________________________________________________________________

28. If business were to be terminated for default on this or any other contract, would there be any financial impact on any of the alleged or acknowledged affiliates or their principals? ____ yes ____ no

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