Supplementary with Comments

Form Approved, OMB No. 2900-0675

Respondent Burden: 30 minutes

Expiration Date xx-xx-xxx

VETBIZ VENDOR INFORMATION PAGES VERIFICATION PROGRAM

INSTRUCTIONS: Please provide the name of the company and its Data Universal Numbering System (DUNS) number. All stockholders/owners must provide Title, First, Last, Middle Name, Percentage of Business Ownership, Veteran Status, Social Security Number or File Number, Date of Birth (SSN/File Number and DOB only applies to Veterans or eligible Surviving Spouse) and sign the form. Total ownership must equal 99-100%. VA will not accept applications from owners/stockholders who are not Veterans. DO NOT MAIL OR EMAIL the form.

PART I - CONSENT TO ACCESS AND VERIFY VETERAN(S) OWNER(S)/VETERAN(S) STOCKHOLDER(S) RECORD(S)

Each Veteran owner/Veteran stockholder named herein authorizes consent for the Center for Veterans Enterprise (CVE) personnel to access and verify their records. CVE will match your information with records maintained by the Department of Veterans Affair .

NAME OF COMPANY DBA DUNS

First Name

Middle Name

Last Name

Jr, Sr, III etc.

NAME(S) OF EACH BUSINESS OWNER/STOCKHOLDER/ SURVIVING SPOUSE (Mr./Ms., First Name, Middle, Last, Jr./Sr./III)

% OF OWNER- SHIP

VETERAN STATUS

VETERAN

SVC. DIS. VETERAN

SURVIVING SPOUSE

NON-VET

SSN/VA FILE NO./ CLAIM NO. FOR VETERAN(S) & SURVIVING SPOUSE ONLY (Skip if Non-Veteran)

DATE OF BIRTH

SIGNATURE OF EACH BUSINESS OWNER(S)

DATE SIGNED

PART II - AFFIRMATION

By signing this form, I affirm that the legal documents establishing the business are filed with my state and such articles established that at least 51% of the business is owned and controlled (or in the case of stock, at least 51% of the stock is owned) by Veterans or service-disabled Veterans, or eligible surviving spouses, as stated in Public Law 109-461 Section 8127 (k) (2). I affirm that each of the owners of the business (or in the case of a business with stock, each of the stockholders) is eligible to participate in Federal contracting and that neither the business nor any of the individual owners appears on the Excluded Parties List at as identified in Federal Acquisition Regulation 9.404-3. I further affirm that I have read and understand the language in 13 CFR 125.10 and that the business is controlled by individuals eligible to participate in the SDVOSB program if I am claiming SDVOSB status. A false statement on any part of your application may be punished by fine or imprisonment (U.S. Code title 18, section 1001). I understand that any information I give may be investigated as allowed by law or Presidential order. I certify that, to the best of my knowledge and belief, all of my statements are true, correct, complete, and made in good faith. Misrepresentations of VOSB or SDVOSB eligibility may result in action taken by VA officials to debar the business concern for a period not to exceed 5 years from contracting with VA as a prime contractor or a subcontractor.

PRIVACY ACT STATEMENT: The Privacy Act of 1974, 5 U.S.C. 522a (e), requires that all agencies publish in the Federal Register, a notice of the existence and character of their systems of records. VA system of records titled VA VetBiz Vendor Information Pages (123VA00VE) covers the information being provided on this form. The information collected on this form is necessary to meet the eligibility of veteran-owned small business concerns under Public Law 109-461, Section 8127 requirements. We will use the information to identify any VA records. Furnishing the information on this form, including your Social Security Number (No.) and VA File/Claim No. is voluntary; however, if the information is not furnished, VA will not recognize your small business as veteran-owned or service-disabled veteran-owned. Your obligation to respond is voluntary.

PAPERWORK REDUCTION ACT NOTICE: The collection of information meets the requirement of Public Law 109-461, Section 8127 (f) 4, as amended by Section 2 of the Paperwork Reduction Act of 1995. This form has been created to provide an efficient way for the Department of Veterans Affairs to collect and verify Veterans and service-disabled Veterans in the Vendor Information Pages (VIP). We estimate the time to fill out the form to be about 5 minutes to read the instructions, gather the facts, and answer the questions. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed.

VA FORM DEC 2010

0877

SUPERSEDES VA FORM 0877, NOV 2008,WHICH WILL NOT BE USED.

PART I - CONSENT TO ACCESS AND VERIFY VETERAN(S) OWNER(S)/VETERAN(S) STOCKHOLDER(S) RECORD(S) (Continued)

NAME(S) OF EACH BUSINESS OWNER/STOCKHOLDER/ SURVIVING SPOUSE (Mr./Ms., First Name, Middle, Last, Jr./Sr./III)

% OF OWNER- SHIP

VETERAN STATUS

VETERAN

SVC. DIS. VETERAN

SURVIVING SPOUSE

NON-VET

SSN/VA FILE NO./ CLAIM NO. FOR VETERAN(S) & SURVIVING SPOUSE ONLY (Skip if Non-Veteran)

DATE OF BIRTH

SIGNATURE OF EACH BUSINESS OWNER(S)

DATE SIGNED

VA FORM 0877, DEC 2010, page 2

SUPERSEDES VA FORM 0877, NOV 2008,WHICH WILL NOT BE USED.