Form SBA FORM 1450 SBA FORM 1450 8(a) Annual Update

OMB APPROVAL NO. 3245-0205
Expiration Date: 05/31/2012

8(a) ANNUAL UPDATE
Under 15 USC 636(j)10) each Program Participant is required to submit a business plan to SBA as condition of participation
and to review that plan with the Agency annually. SBA is collecting this information to ensure continuing eligibility for
participation in the 8(a) Business Development Program to the requirements listed in 13 CFR 124.112.
All information collected will be protected to the extent permitted by law, including the Freedom of Information Act, (5
U.S.C. 552), Privacy Act (5 U.S.C. 555a) and the Right to Financial Privacy Act of 1978 (12 U.S.C. 3401).

1.

Business Information:
Month / Day/Year

The following fields have been filled with information from SBA records, please review and correct the pre-filled data and enter missing data as appropriate.

Case No.:

SBA Customer
Number:

8(a) Approval Date:

CCR/DSBS Last Updated:
Transition Stage Date:

8(a) End Date:

Company Name:
Address:
City: State:
E-mail Address:

2.

ZIP:
Phone No.:

FAX No:

Personal Financial Information : A Personal Financial Statement, SBA Form 413, must be completed and submitted for
each disadvantaged owner upon whom 8(a) certification was based. Each individual reporting must also include their most
recent tax return, including all schedules, attachments and supporting 1099 forms. [13 CFR 124.112 (b) (3)]

3.

Annual Compensation Data: A record of all payments, compensation, and distributions (including loans, advances salaries
and dividends) made by the participant to each of its owners, officers or directors, or to any person or entity affiliated with such
individuals. Use Individual Compensation Worksheet, Attachment A. [124.112 (b) (5)]

4.

Transferred Assets: A record from each individual claiming disadvantaged status regarding the transfer of assets for less than
fair market value to any immediate family member or to a trust any beneficiary of which is an immediate family member, within
two years of the date of this annual review. [124.112 (b) (4)] Have any assets been transferred since last review. Yes
No
If yes, please explain on a separate sheet of paper.

5.

Business Tax Return: A copy of the participant firm’s most recent year-end business tax return including all schedules and
attachments and a completed copy of IRS Form 4506, request for copy or transcript of Tax Form must be included with this 8(a)
annual update. [124.112 (b) (7)]

6.

Business Structure/Ownership Changes:

7.

Adverse Actions: Are there any pending adverse actions (such as lawsuits, delinquent taxes, bankruptcy filings, creditor

Have there been any changes in the Partnership Agreement, Articles of
Incorporation, By-Laws or stock issues since your firm was certified for 8(a) participation that have not been previously reported
No
If yes, please submit information about those changes with this annual update. [124.112 (a)]
to SBA? Yes

problems, contract disputes, etc.) which may affect your business operation? Yes
sheet of paper. [124.112 (b) (2)]

8.
9.

No

If yes, please explain on a separate

Business Financials: Copy of latest firm’s Balance Sheet and Income Statements.
Access to credit and Capital: List all loans, lines of credit or other sources of capital available to the participant firm.
[124.302 (b) (3)]

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9.
Contin Loan(s): Provide the following information for each loan.
ued:
Source:

Date of Loan:
Month / Day /Year

Purpose of Loan:
Original Amount: $

Balance: $

Status of Loan:

Secured
Terms:
by:

Line(s) of Credit: Provide the following information for each line of credit.
Source:

Date of Loan:
Month / Day /Year

Purpose of Loan:
Original Amount: $

Balance: $

Status of Loan:

Secured
Terms:
by:

10.

Other Sources of Capital: Please list all other sources of capital available to participant firm.
Source:

Date of Loan:
Month / Day /Year

Purpose of Loan:
Original Amount: $

Balance: $

Status of Loan:

Secured
Terms:
by:

11.

Bonding Information: If a construction firm, what is current bonding limit? [124.302 (b) (4)]
Single job: $

Aggregate: $

Individual Surety:
Is SBA guaranty required?

12.

Corporate Treasury Listed Surety:
————————

Yes

No

Sometimes

Business Activity Report: On a separate sheet of paper provide a report of all non-8(a) contracts, options and modifications
affecting price executed during the program year. Indicate below, total of all non-8(a) revenue and 8(a) revenue earned during
the program year. [124.509 (c) (ii)]
This report will be made for the program year starting on
Month/ Day/ Year

Non-8(a) sales:
8(a) sales
Total sales
for program year:

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.

and ending

$
$
$
$

(
(
(
(

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Month/ Day/ Year

%)
%)
%)
100 %)

How many competitive solicitations (private, federal, state or local) have you responded to within the last program year?
Commercial:

Local government:

State government:

Federal Non-8(a):

Federal 8(a):

Total:

Please explain on a separate sheet of paper the efforts made by your firm to pursue non-8(a) sales during the last program year.

13.

Number of Employees: Please indicate how many employees you have.
Full time

Part time

as of
Month/Day/Year

14. Mentor/Protégé: For the program year being reviewed were you a participant in an SBA approved or any approved
mentor/protégé agreement? [124.520]
Worksheet:

Yes

No If yes please complete Attachment “B” Mentor/Protégé

15. Joint Venture: Are you a participant in a joint venture (JV) agreement(s)?
Yes

No

For each joint venture indicate:
JV Name

JV Partner

16.

[124.513]

Award date

Prime Contract #

by jurisdiction:

Taxes: Indicate taxes your firm paid for fiscal year ending
Federal: $
State: $
Local: $

17.

Contract Forecast: Each participant must annually forecast its needs for contract awards for the next program year. The
forecast must include the aggregate dollar value of 8(a) contracts broken down by sole source and competitive opportunities
where possible; the aggregate dollar value of non-8(a) contract; the types of contract opportunities identified by product or
service. [124.403 (b)]
8(a) Forecast
Sole Source
Competitive $
Total $

Non-8(a) Forecast

$

$
$
$

Total Forecast (includes both 8(a) and Non-8(a)): $

Briefly identify the types of contract opportunities sought.

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Transition Management Plan
Beginning in the first year of the transitional stage of program participation (years 5 through 9) each participant must annually submit a
transition management strategy to be incorporated into its business plan. This transition management strategy must describe: 124.403 ©

How you plan to meet the applicable non-8(a) business activity targets, imposed by 124.509 during the transitional stage.
[124.403 (c) (1)]

Indicate the specific steps you intend to take to continue business growth and promote profitable business operations
after the expiration of your program term. [124.403 (c) (2)]

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CERTIFICATIONS
PARTICIPANT FIRMS OWNED BY INDIAN TRIBES, ALASKA NATIVE CORPORATIONS, NATIVE
HAWAIIAN ORGANIZATIONS OR COMMUNITY DEVELOPMENT CORPORATIONS SHALL CERTIFY
THEY MEET ALL THE 8(a) PROGRAM ELIGIBILITY REQUIREMENTS AS SET FORTH IN 13 CFR
124.112 TO THE EXTENT THAT THEY ARE NOT INCONSISTENT WITH 124.109, 110 AND 111.
PARTICIPANT FIRMS NOT OWNED BY THOSE ENTITIES SPECIFIED ABOVE SHALL CERTIFY THEY
MEET THE REQUIREMENTS OF 13CFR 124.101 THROUGH 124.108.
I CERTIFY THAT ALL INFORMATION SUBMITTED IN THIS 8(a) ANNUAL UPDATE, ATTACHMENTS,
AND THE PERSONAL FINANCIAL STATEMENT IS TRUE, CORRECT AND ACCURATE.

Signature of President, Partner or Proprietor

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Date

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Attachment A

INDIVIDUAL COMPENSATION WORKSHEET

Annual Compensation Data : To be provided for each proprietor, partner, officer, director, and each stock holder owning 10% or
more of the company stock. Annual compensation includes all payments, compensation, and distributions, including loans, advances,
salaries and dividends. Each individual reporting must include a signed and dated copy of their most recent tax return, including all
schedules and attachments. In addition, all supporting 1099 forms must be provided. If a filing extension has been requested, provide a
copy of IRS Form 4868, Individual extension request, and a copy of their most recently signed and dated tax return. Tax information
provided may be verified with IRS.[124.112(b)(5)]

Name:

Title:

Ownership %
SBA Customer
Number:

Company Name:
Loans: Does your firm have any outstanding loan(s) to you? Yes
loSource:
an
.
Original Amount: $

No

If yes, please provide the following information for each
Date of Loan:

Status:
Month/Day/Year

Balance: $

Terms:

Secured by:
Purpose of Loan:

Annual Compensation:
Salary $
Bonus(es) $
Advances $
Dividends $
Distributions $
Other compensation, please specify

$
$
$

Total Compensation for period of

Through
Month/Day/Year

Total Compensation for previous year ending

$
Month/Day/Year

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$
Month/Day/Year

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Attachment B

MENTOR/PROTÉGÉ WORKSHEET
Your firm participated in or continues to participate in an any approved mentor/protégé agreement with whom:
Date this agreement was approved:
Is your firm the mentor

or the protégé?

Period of agreement:
? If your firm is the protégé, the following information must be provided. [124.520 (f)]

List all technical and/or management assistance provided by the mentor to the protégé.

List all loans to and/or equity investments made by the mentor in the protégé.

List all subcontracts awarded to the protégé by the mentor and the value of each subcontract.

List all federal contracts awarded to the mentor/protégé relationship as a joint venture (designating each as an 8(a), small business set
aside, or unrestricted procurement), the value of each contract, and the percentage of revenue accruing to each party to the joint venture.

Provide a narrative describing the success such assistance has had in addressing the developmental needs of the protégé and addressing
any problems encountered.

The protégé must annually certify to SBA whether there has been any change in the terms of the mentor protégé agreement. If there
were no changes, please state so, or if there were changes, please indicate.

PLEASE NOTE: The estimated burden for completing this form is 2 hours . 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, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503. OMB Approval (3245-0205). PLEASE DO NOT SEND FORMS
TO OMB.

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8(a) PARTICIPANT BENEFITS REPORT

Who Submits this Benefits Report Form?: All 8(a) Participant firms owned by a Tribe, ANC, NHO, or CDC. The
parent corporation can submit the requested information on behalf of all the individual subsidiary 8(a) participant firms
owned by the respective Tribe, ANC, NHO, or CDC.. For this benefits report, the entity completing this form (either the
individual Participant firm or the parent corporation) is considered the “Reporting Entity.” All responses must correlate to
the annual business financial statements submitted to SBA.
CATEGORIES OF BENEFITS
When completing Section II refer to the following six (6) categories that represent an area where benefits are potentially
provided to the Native or other communities through the subsidiaries’ or the Participant firm’s participation in the 8(a)
program.
Each of the following categories solely applies to this reporting requirement and this form.
Category 1: Health, Social and Cultural Support
The following types of contributions fall within the category of “Health, Social, and Cultural Support” benefits that
the Reporting Entity should report below in Section II:


Monetary donations or contributions made by the Reporting Entity including 8(a) Program Participants for the
benefit of the Native or other communities as a direct or indirect result of its subsidiaries’ participation in the 8(a)
program.



Social programs established and/or funded by the Reporting Entity for the benefit of the Native or other
communities as a direct or indirect result of its subsidiaries’ participation in the 8(a) program.



Cultural programs established and/or funded by the Reporting Entity for the benefit of the Native or other
communities as a direct or indirect result of its subsidiaries’ participation in the 8(a) program. This may include
language revitalization programs, cultural camps, and after school programs.



Beneficiary outreach and communication efforts established and/or funded by the Reporting Entity as a direct
or indirect result of its subsidiaries’ participation in the 8(a) program. This may include newsletters, websites,
conferences, informational meetings, gatherings, and annual meetings of Native or community members.



Death benefits established and/or funded by the Reporting Entity as a direct or indirect result of its
subsidiaries’ participation in the 8(a) program. This may include funeral benefits, life insurance proceeds,
and potlatch funds.

Category 2: Education and Development
The following types of programs fall within the category of “Education and Development” benefits that the
Reporting Entity should report in below in Section II:


Scholarship programs established and/or funded by the Reporting Entity for the benefit of the Native or other
communities as a direct or indirect result of its subsidiaries’ participation in the 8(a) program.
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

Life skills programs established and/or funded by the Reporting Entity for the benefit of the Native or other
communities as a direct or indirect result of its subsidiaries’ participation in the 8(a) program.



School program support established and/or funded by the Reporting Entity for the benefit of the Native or other
communities as a direct or indirect result of its subsidiaries’ participation in the 8(a) program.



Apprentice programs established and/or funded by the Reporting Entity for the benefit of the Native or other
communities as a direct or indirect result of its subsidiaries’ participation in the 8(a) program.



Intern programs established and/or funded by the Reporting Entity for the benefit of the Native or other
communities as a direct or indirect result of its subsidiaries’ participation in the 8(a) program.



Training programs established and/or funded by the Reporting Entity for the benefit of the Native or other
communities as a direct or indirect result of its subsidiaries’ participation in the 8(a) program, including Board,
Tribal Council, and Management training programs and mentor programs.

Category 3: Lands
The following types of programs and initiatives fall within the category of “Lands” benefits that the Reporting
Entity should report in below in Section II:


Land management programs established and/or funded by the Reporting Entity for the benefit of the Native or
other communities as a direct or indirect result of its subsidiaries’ participation in the 8(a) program.



Subsistence programs (e.g., agriculture farming) established and/or funded by the Reporting Entity for the
benefit of the Native or other communities as a direct or indirect result of its subsidiaries’ participation in the 8(a)
program.



Contributions made by the Reporting Entity as a direct or indirect result of its subsidiaries’ participation in the
8(a) program to improve resource management and enforcement for the benefit of the Native or other
communities.



Contributions made by the Reporting Entity as a direct or indirect result of its subsidiaries’ participation in the 8(a)
program to improve water management for the benefit of the Native or other communities.

Category 4: Economic and Community Development


The following types of programs and initiatives fall within the category of “Economic and Community
Development” benefits that the Reporting Entity should report in below in Section II:



Investment in new businesses made by the Reporting Entity as a direct or indirect result of its subsidiaries’
participation in the 8(a) program.



Community infrastructure established and/or funded by the Reporting Entity for the benefit of the Native or
other communities as a direct or indirect result of its subsidiaries’ participation in the 8(a) program.



Support to small businesses or entrepreneurs given by the Reporting Entity as a direct or indirect result of its
subsidiaries’ participation in the 8(a) program benefitting the Native or other communities.



Federal and state tax payments made by the Reporting Entity that directly benefited the Native or other
communities.



Housing Assistance given by the Reporting Entity as a direct or indirect result of its subsidiaries’ participation in
the 8(a) program benefiting Native or other communities.
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

Energy Assistance given by the Reporting Entity as a direct or indirect result of its subsidiaries’ participation in
the 8(a) program benefiting Native or other communities.

Category 5: Employment
The following types of programs and initiatives fall within the category of “Employment” benefits that the
Reporting Entity should report in below in Section II:


Total number of jobs directly or indirectly created by the Reporting Entity Subsidiaries’ participation in the
8(a) program benefiting the Native or other communities.



Programs or initiatives created for employment assistance and support benefiting the Native or other
communities as a direct or indirect result of the Reporting Entity subsidiaries’ participation in the 8(a) program.

Category 6: Economic Benefits


The following types of contributions and investments fall within the category of “Economic Benefits” that the
Reporting Entity should report in below in Section II:



Investment or payments made by the Reporting Entity for the support of elder trusts as a direct or indirect result
of its subsidiaries’ participation in the 8(a) program.



Investment or payments made by the Reporting Entity for the support of settlement trusts as a direct or indirect
result of its subsidiaries’ participation in the 8(a) program.



Investment or payments made by the Reporting Entity towards permanent funds or restricted funds as a direct or
indirect result of its subsidiaries’ participation in the 8(a) program.



Dividends paid by the Reporting Entity as a direct or indirect result of its subsidiaries’ participation in the
8(a) program.



Increase in the value of the equitable interest in the Reporting Entity as a direct or indirect result of its
subsidiaries’ participation in the 8(a) program for the past fiscal year.

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SECTION I - ENTITY INFORMATION –

1. Eligibility: Check all categories that apply (including whether the Reporting Entity is representative of an American
Indian Tribe, ANC, NHO, or CDC or whether the Reporting Entity is owned through a wholly-owned holding
company):

 American Indian Tribe

 ANC

 CDC

 Wholly-Owned
Holding Company

 NHO

2. Name of Reporting Entity (if different legal entity than the Participant Firm) – American Indian Tribe, ANC, NHO, CDC, or
Wholly-Owned Holding Company Owner of Participant(s):
__________________________________________________________________________
Address of Reporting Entity: __________________________________________________
City: ________________________________
State: ____________________

County: ______________________

Zip Code: ________________

3. Reporting Entity Point of Contact Information:
Name: ____________________________ Position Held: ______________________
Address: ______________________________________________________________
City: ___________________________ State: ________ Zip Code: _____________
Email Address: ________________________________________________________
Business Telephone: ___________________ Fax Number: ____________________

4. List the names of the current 8(a) Program Participants owned by the Reporting Entity during the applicable fiscal year and
the years in which the firms were certified in the 8(a) program. If more space is needed, provide in an attachment marked
as “Attachment – Names of current 8(a) Participant Firms.” If the Reporting Entity and the Participant firm are the same
legal entity, then only complete the first line below with information for the one firm.
Name

8(a) Participant
Number

Year
Certified

Total Revenue

8(a)
Revenue

5. Actual net income generated by all 8(a) Program Participant(s): ___________________
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Non-8(a)
Revenue

a) Estimated net income generated by Reporting Entity’s 8(a) contracts, excluding non-8(a) work from “6.” above:
___________________
b) Summarize the methodology utilized in determining the estimate of the net income generated above. If more space is
needed, provide in an attachment marked as Attachment I.6.a.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
____________

c) Is a portion of the net income generated by the 8(a) Program Participant(s) being reinvested into the corporate entities
owned by the Reporting Entity? Net income is considered to be reinvested if the Reporting Entity keeps the earnings in
the 8(a) firm or in any another subsidiary of the Reporting Entity to increase its capital accounts or make the funds
available in a capital investment, hiring of personnel, or otherwise expand the existing corporate entities’ businesses
and/or market share.
□ Yes

□ No If yes, what percentage? _________________

SECTION II – SBA BENEFITS REPORTING CATEGORIES
Below are six (6) specific categories SBA has identified as potentially providing benefits to the Native or other communities
through the firm’s participation in the 8(a) program. Answer each question, making sure to list and describe all applicable
programs, initiatives, donations, and investments of funds through the 8(a) participant or other business enterprise.
Each category has a section where the Reporting Entity is provided the opportunity to offer a narrative statement describing
both tangible and intangible contributions 8(a) program participant(s) have made to the Native or other communities.
The seventh category allows the Reporting Entity to self-identify and report any contribution or benefit not encompassed in
the prior six (6) specific categories.

Background Narrative
a) Provide a narrative statement describing the community, culture, and history of the Native or community organization
associated with the Reporting Entity. If more space is needed, provide in an attachment marked as “Benefits
Attachment Background Narrative.”
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
___________________________________________________________
b) If Reporting Entity and/or Participant Firm is Native-owned, state the number of tribal members, shareholders, or Native
Hawaiians in Tribe, ANC, or NHO: _________________
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c) If Reporting Entity and/or Participant Firm is a CDC, state the number of members in the community serviced by CDC:
_____________
1. Health, Social and Cultural Support - Category 1
This category encompasses contributions made by the Reporting Entity and/or Participant Firm to the Health, Social,
and Cultural Support of the Native or other communities. The Reporting Entity and/or Participant Firm should
identify the total financial contribution made for all programs under this category. List the programs supported and, if
known, estimate the total number of beneficiaries and total financial contribution of each identified program.
Total financial contribution:

_________________

Program

Beneficiaries

Financial
Contribution

Provide any additional narrative/information describing Health, Social, and Cultural Support programs established and/or
funded by the Reporting Entity and/or Participant Firm for the benefit of the Native or other communities and beneficiaries
as a direct or indirect result of its subsidiaries’ participation in the 8(a) program, including intangible benefits to the
beneficiaries. If more space is needed, provide in an attachment marked ”Benefits Attachment Category 1.”
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
____________________________________________________
2. Education and Development – Category 2
This category encompasses programs funded by the Reporting Entity and/or Participant Firm to support the Education and
Development of the Native or other communities. The Reporting Entity and/or Participant Firm should identify the total
financial contribution made for all programs under this category. List the programs supported, and, if known, estimate the
total number of beneficiaries and total financial contribution for each identified program.
Total financial contribution:

_________________

Program

Beneficiaries

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Financial
Contribution

Provide any additional narrative/information describing Education and Development programs established and/or funded
by the Reporting Entity and/or Participant Firm for the benefit of the Native or other communities as a direct or indirect
result of its subsidiaries’ participation in the 8(a) program, including intangible benefits to the beneficiaries. If more space
is needed, provide in an attachment marked ”” Benefits Attachment Category 2”.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
____________________________________________________
3. Lands Category 3
This category encompasses programs and initiatives funded by the Reporting Entity and/or Participant Firm to support the Lands
of the Native or other communities. The Reporting Entity and/or Participant Firm should identify the total financial
contribution made for all programs under this category. List the programs supported, and, if known, estimate the total number of
beneficiaries and total financial contribution of each identified program.

Total financial contribution:

_________________

Program

Beneficiaries

Financial
Contribution

Provide any additional narrative/information describing Lands programs and initiatives established and/or funded by the
Reporting Entity and/or Participant Firm for the benefit of the Native or other communities as a direct or indirect result of its
subsidiaries’ participation in the 8(a) program, including intangible benefits to the beneficiaries. If more space is needed,
provide in an attachment marked ” Benefits Attachment -Category 3”.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
____________________________________________________
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4. Economic and Community Development Category 4
This category encompasses programs and initiatives funded by the Reporting Entity and/or Participant Firm to support
the Economic and Community Development of the Native or other communities. The Reporting Entity and/or
Participant Firm should identify the total financial contribution made for all programs under this category. List the
programs supported, and if known, estimate the total number of beneficiaries and total financial contribution for each
identified program.
Total financial contribution:

_________________

Program

Beneficiaries

Financial
Contribution

Provide any additional narrative/information describing Economic and Community Development programs and initiatives
established and/or funded by the Reporting Entity and/or Participant Firm for the benefit of the Native or other communities
as a direct or indirect result of its subsidiaries’ participation in the 8(a) program, including intangible benefits to the
beneficiaries. If more space is needed, provide in an attachment marked ”Benefits Attachment - Category 4”.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
____________________________________________________
5. Employment Category 5
This category encompasses programs and initiatives funded by the Reporting Entity and/or Participant Firm to support
Employment in the Native or other communities. The Reporting Entity and/or Participant Firm should identify the total
financial contribution made for all programs under this category, including the estimated total amount of wages paid to
Natives and amount of employment taxes by the Reporting Entity and/or Participant Firm or its subsidiaries as a direct or
indict result of the subsidiaries’ participation in the 8(a) program (including the Reporting Entity and/or Participant Firm’s
and subsidiaries’ Board or Tribal Council for service).
Total Financial Contribution: ____________
Estimated Total Amount of Wages Paid to Natives, Members, etc. _________________
Estimated Total Amount of Employment Taxes: _______________________
i) Report the total number of jobs created by the Reporting Entity and/or Participant Firm’s subsidiaries (include the total
number of individuals employed, regardless of location of employment):
Total jobs created: _______________________
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Total jobs to Natives, Members, etc.: _________
Total jobs to Non-Natives, non-Members, etc.: _________
ii) Report the total number of jobs directly or indirectly created in the respective communities as a result of the Reporting
Entity subsidiaries’ and/or Participant Firm’s participation in the 8(a) BD program, including the sectors of the
economy (identified by NAICS codes) in which these jobs were created. If more space is needed, provide an attachment:
Total jobs created in the community: ________
iii) List and describe any programs or initiatives created for employment assistance and support benefiting the Native or
other communities as a direct or indirect result of the Reporting Entity subsidiaries’ participation in the 8(a) program.
The Reporting Entity should list programs supported and estimated total number of beneficiaries.
Program

Beneficiaries

Provide any additional narrative/information describing Employment programs and initiatives established and/or funded by
the Reporting Entity and/or Participant Firm for the benefit of the Native or other communities as a direct or indirect result
of its subsidiaries’ participation in the 8(a) program, including intangible benefits to the beneficiaries. If more space is
needed, provide in an attachment marked “Benefits Attachment – Category 5.”
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
____________________________________________________
6. Economic Benefits Category 6
This category encompasses Economic Benefits, including investments, payments, and dividends, derived from participation
in the 8(a) program. The Reporting Entity and/or Participant Firm should identify the total financial contribution made for
all programs under this category. List the programs supported, and if known, estimate the total number of beneficiaries
served and total financial contribution for each identified program.
Total financial contribution: _________________
Program

Beneficiaries

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Financial
Contribution

Provide any additional narrative/information describing Economic Benefits, including both investments, payments, and
dividends, derived from participation in the 8(a) program benefiting the Native or other communities, including intangible
benefits to the beneficiaries. If more space is needed, provide in an attachment marked “Benefits Attachment – Category
6.”
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
____________________________________________________
7. Other Activities – Category 7
This category encompasses any other benefits derived from participation in the 8(a) program not covered by the specific six
categories above. The Reporting Entity and/or Participant Firm should identify the total financial contribution made for all
programs under this category. List the programs supported, and, if known, estimate the total number of beneficiaries served
and total financial contribution for each identified program.
Total financial contribution:

_________________

Program

Beneficiaries

Financial
Contribution

Provide a narrative statement detailing any other benefits the Reporting Entity and/or Participant Firm provides to the
Native or other communities not encompassed by the categories above, as a result of its subsidiaries’ participation in the
8(a) program, including intangible benefits to the beneficiaries. If more space is needed, provide in an attachment marked
“Benefits Attachment – Category 7.”
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
____________________________________________________
SECTION III – SUMMARY OF BENEFITS
The following information should reflect an aggregation of the information provided above in Section II.
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1. Provide the percentage of the estimated 8(a) government contracting net income applied to all benefits listed within Section
II above: _______________
2. Provide any additional narrative/information describing how the Reporting Entity and/or Participant Firm determines net
income allocations towards benefits, reinvestment into the corporate entities, or utilized to invest in new business
opportunities. If more space is needed, provide in an attachment marked Attachment: Section III Summary of Benefits, 2.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_____
SECTION IV – CERTIFICATION on BENEFITS REPORTING
This certification is to be completed by the highest officer of the parent corporation. (CEO or President).
By signing this form, I certify under penalty of criminal prosecution that all information on this form and any additional
supporting information submitted with this form are true and complete to the best of my knowledge. I understand that SBA
will rely on this information regarding each subsidiary’s participation in the SBA 8(a) Business Development program and
I understand that failure to submit this form may result in termination of all subsidiaries from the SBA 8(a) Business
Development (BD) program.

_______________________________________________
Name of Reporting Entity
By: ___________________________________________
Signature of Highest Officer of Parent/Reporting Entity
(CEO or President)
Name and Title: _________________________________
Date of Signing: _________________________________

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