Form SBA Form 2298 SBA Form 2298 Annual Survey of SBA HUBZone Small Business Concerns Awa

OMB Control OMB Control No. 3245-0350

Expiration date 08/30/2013

U.S. Small Business Administration

Washington, D.C. 20416

Annual Survey of SBA HUBZone Small Business Concerns

Awarded HUBZone Contracts

Please complete the following information and reply to this e-mail via URL [email protected]. The form should be filled out by the firm that is performing the contract. To reduce the burden of completing the questionnaire, some of the fields are already populated with information previously provided by the firm to the HUBZone Program, the Dynamic Small Business System or the FPDS-NG. In these cases, please review the data and edit them as necessary. If there are discrepancies in the data, HUBZone personnel will contact the firm. Providing the requested information, as authorized by the program regulations at 13 CFR 126.403(b), will help SBA assess the economic impact of the HUBZone Program.

Assurance of Confidentiality: Your responses will be automatically encrypted and accessible to a limited number of SBA personnel authorized to access the information on a need-to-know basis only. SBA will keep the information confidential to the full extent permitted by law, including the Freedom of Information Act, 5 U.S.C 552 and the Right to Financial Privacy Act, 12 U.S.C. 3401.et seq.

Section I

1. Name of firm: ___(Provided by DSBS)____________________________________________

Note: Is this name the one used for this firm on its latest Internal Revenue Service Form 941, Employer’s Quarterly Federal Tax Return? Yes No If you answer no, please provide the name of the firm used on the form 941 below).

2. Name of the firm used on Form 941: ___________________________________________________

3. Doing Business As (DBA): (DSBS) ___________________________________________

4. SBA ID Number (DSBS Number): _______(Provided by DSBS)__________________________

5. Employer identification Number (EIN): _(Provided by DSBS)_____________________________

Note: Is this number the one used for this firm on its latest Internal Revenue Service Form 941, Employer’s Quarterly Federal Tax Return? Yes No If you answer no, please provide the number of the firm used on the Form 941 below.)

Note: This is the ID number that appears in the URL address of the firm in DSBS.

6. EIN used on Form 941: _________________________________

7. DUNS Number of the office of the firm performing the contract:

__(Provided by FPDS-NG/DSBS)_______________________________________________

8. Address of the firm performing the contract:

(Note: Address will be provided from the Contract information to be reviewed by the firm)

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

9. Additional DUNS numbers of the firm:

Please identify additional DUNS numbers related to the firm, identify the main office and branches, and finally identify the DUNS corresponding to the HUBZone principal Office.

DUNS Number	Address 1	Address 2	City	State	Zip code	HUBZone Principal Office (Mark with an X)

10. Place of Contract Performance:

Note: If the contract is performed in one or more job sites, please provide the address of the primary office the employees should report to, and the address(es) of each job site.

Office	Address 1	Address 2	City	State	Zip code
Job site 1
Job Site 2
Job Site 3

IF needed, please continue adding lines.

Section 2

1. Please provide the Total gross Revenue from the last three years of financial statements of the firm.

_________________________________________________________

Total Gross Revenue Includes the total sales, shipments, receipts, revenue, or business done by the firm (in dollars):	2010	2011	2012
	$	$	$
Average Total Gross Revenue (3 years)	AutoCalculated

2. Please provide the following information about employees. Please follow the instructions.

2.a. Employment and Payroll Include Full and part time employees working at this office whose payroll was reported on the firm’s Internal Revenue Service Form 941, Employer’s Quarterly Federal Tax Return.
Number of Employees (From line 1, Part 1 Form 941):	2012	2011
March 12
June 12
September 12
December 12
Average Annual Employees	AutoCalculated		Autocalculated

2.b. Number of Employees in Payroll that reside in a HUBZone From the number of employees in the previous table, please identify the number of employees as defined in the attached definitions that reside in a HUBZone. (Definition: The term “Employee” means all individuals employed on a full-time, part-time, or other basis, so long as that individual works a minimum of 40 hours per month.)
HUBZone Employees in payroll	2012		2011
March 12
June 12
September 12
December 12
Average Annual HUBZone Employees in Payroll	Auto calculated	Auto calculated

2.c. Number of Leased Employees Firms with "leased employees" (whose payroll is filed with the IRS by an employee leasing company, not the company performing the contract, are considered employees of the HUBZone firm.) :
Total Number of Leased Employees	2012	2011

Number of Leased Employees residing in a HUBZone

2012

2011

2.d. Other Type of non-Payroll Employees This includes contract employees, employees obtained from a temporary employee agency, or through a union agreement or co-employed pursuant to a professional employer organization agreement. :
Number of Other Type of Non-Payroll Employees	2012	2011

Number of Other Type of Non-Payroll Employees that reside in a HUBZone

2012

2011

Annual Payroll (Exclude Employer’s Cost for fringe benefits-see definition in attached)
Annual Payroll (From Part I of the 941 Form) in dollars	2012	2011

Section 3

This section will be completed for every contract performed in the year. If a firm has multiple contracts, then it will be possible to fill out only the information that was not entered previously. This will be a feature of the web questionnaire.

Job retention and Creation related to Awarded HUBZone Contracts
Type of Award	(Populated from FPDS-NG)
Type of HUBZone Set-Aside (Set-Aside or Sole Source)	(Populated from FPDS-NG)
HUBZone Price Evaluation Preference	(Populated from FPDS-NG)
Actions	(Populated from FPDS-NG)
Total Contract Value (in dollars)	(Populated from FPDS-NG)
Action Obligations (in dollars)	(Populated from FPDS-NG)
Effective date	(Populated from FPDS-NG)
Completion date	(Populated from FPDS-NG)
How many payroll employees were hired or retained as a result of this contract?	Retained:
	New:
How many HUBZone payroll employees were hired or retained as a result of this contract?	Retained:
	New:
How many non payroll employees were hired or retained as a result of this contract?	Retained:
	New:
How many non payroll HUBZone employees were hired or retained as a result of this contract?	Retained:
	New:
Capital expenditure as a result of this contract (in dollars) Note: This item includes permanent additions and major alterations as well as new and used machinery and equipment. Please see definitions for more detail.	$

Please Note:  The estimated burden for completing this questionnaire is 30 minutes per response. You are not required to respond to this request for information unless it displays a currently valid OMB Control number. Comments on the burden should be sent to U.S. Small Business Administration, Chief, AIB, 409 3^rd Street, S.W., Washington, DC, 20416, and Desk Officer for Small Business Administration, Office of Management and Budget, New Executive Bldg., Rm 10202 Washington, DC 20503. OMB Control # (3245-0350). PLEASE DO NOT SEND FORMS TO OMB.

CERTIFICATION

WARNING: By submitting this information you are representing on your own behalf and on behalf of the HUBZone Small Business Concern that the information provided in the responses to this survey and any document or supplemental information submitted is true and correct as of today’s date. Any intentional or negligent misrepresentation of the information contained in your responses 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 non-procurement transactions; and 5) program termination.

Your name: ___________________________________________

Title: ___________________________________________

Today’s Date: ______________________________________