Form SBA Form 1531 SBA Form 1531 Application for Certificate of Competency

Control No. 3245-0225
Exp. Date: 9/30/2014

SMALL BUSINESS ADMINISTRATION

APPLICATION FOR CERTIFICATE OF COMPETENCY

COC Case Number:

Instructions: The Certificate of Compentency (COC) program allows a small business to appeal a contracting officer's determination that it is unable to fulfill the
requirements of a specific government procurement (or sale) contract on which it is the apparent successful offeror. This form (SBA Form 1531) should be completed by
a small business concern seeking a COC determination from SBA affirming that it is responsible to perform the specific contract. The small business must complete
questions 10-18 in Part I. (SBA will complete questions 1-9 and 19), all questions in Parts II and III, and the certification in Part IV. The completed form must be submitted
to an SBA Area Director serving your geographic area. For more information visit, http://www.sba.gov/content/certificate-competency-program
Basis of Referral:
Capacity

PART I

Credit

D

1. U.S. Small Business Administration (Office)

T&P

Int.

D

D

Other

D

D

Procurement Designation (Solicitation Number)
SetAside

D

Unrestricted

D

2. Next Apparent Successful Offeror-- Whether large or small business,
price difference.
3. Name and Address of Contracting Agency

Buyer
Phone
C/0
Phone

----------------------------_
-----------------------------

Email
Fax
4. Name of Company, Address (Street, City State, ZIP Code)

County:

Email Address:

County:

Contact Name:

9. What are contract delivery and special provision requirements of contract?

SBA Form 1531 (09-2014)

Previous Editions Obsolete

Total Bid
Progress Payments
Available?

Functions at Location

Email:

Yes

Unit Price

d.
e.

Website:

8. Brief Description of Solicited Items or Services

9a. Was Pre-award Survey Conducted?

Increase Option

C.

Title

6. Work Performance Location , if different from the above address
(street, City, State, ZIP Code)

7. Telephone No. (Include Area Code)

Quantity

b.

Principal Company Officials (Attach Resumes)
Name

5. Telephone No. (Include Area Code)

a.

No If so, date of Pre-award Survey Performed

Explain

10. Applicant's directly related experience to solicited items/services

10 (a) Is this a Small Business Set-Aside?
_____Yes

_____No

If Yes answer all that apply below.
•
•
•

Is this small business a Non-manufacturer?
Is this a Supply contract?
Has a NonManfacturer Rule Waiver been issued?

_______Yes
_______Yes
_______Yes

11. Percentage of Government contracts in relation to total sales over 3
yrs
Without
Number of Employees
12.
CoC Contract

______No
______No
______No

%

Attach a list of all current commercial contracts and all
government contracts for past 3 years

With CoC
Contract

Hours of Work

Administrative and Management

No. of Shifts Hours

Production

per Shift Employees

Without
CoC Contract

With CoC
Contract

per Shift Days per

Other

Week
Total
13. Are special skills required?

SBA Form 1531 (09-2014)

DYes

Previous Editions Obsolete

D No

Total Labor hours per week
Are Employees w1th necessary skills
available?

DYes

D No

FACILITlES AND EQUIPMENT

14.

Facility

Area in sq. ft.

List Machinery & Equipment required for this CoC Contract currently available.
List separately additional equipment to be acquired. Use separate sheet if
necessary.

Add'l. for CoC
Contract

Present

(1) Administrative
(2) Manufacturing
(3) Storage- inside
-outside
(4) Other- (specify)

Total
15. Give percentage (dollarwise) of Inventory on hand for the proposed contract

%.
15a. Is the inventory proposed for this contract surplus inventory from another contract? __Yes ___No

o
o

16. Total amount of proposed contract to be subcontracted $

%.

PLANT LOADING AND PRODUCTION SCHEDULES

17.

Total Projected Plant Load Chart (Use a separate line for each existing and proposed contract and each item of present and projected commercial
production. Show start and finish of each item by drawing a line between the month or week started and the month or week to be finished. Use
separate spread sheet if greater detail is needed to evaluate capacity.)

0 Weeks.

0 Months.

Schedule Periods are in

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

A. Commercial
B. Government
C.

CoC Application Contract

D. Other
Present explanation for production and scheduling overlaps; explain delinquent contracts

COST ANALYSIS

18. Check basis

0 Unit Price,

0 Total Contract

Direct Material
Direct Labor g
Overhead
Subcontracting
G&A
SBA USE ONLY

19. Based on data contained in the foregoing and in the attached enclosures a CoC is

0

Recommended

0 Not Recommended

By

0
0

I Concur
I Do Not Concur (State reasons in items)

_

Signature

_
Reviewing
Official

Title
----------------------------

Date

SBA Form 1531 (09-2014)

Previous Editions Obsolete

Title
Date

21

22

23

24

PART II
1. Name of Applicant

CoC Case#

3. Date Business Was Stablished

2. Type of Business (Check)
D Individual Ownership
D Partnership

Month

Year

D Corporation

FINANCIAL STATEMENT
THE FOLLOWING MUST BE FILLED OUT Q.B ITS EQUIVALENT ATTACHED

A.
Balance Sheet As Of

, Fiscal Year Ends
-------------(S-t-t-m-u-s-t b-e-d
-a-te-d-w-iatemen
thin-9-0 day_s_o-ft-he-fi-ling of this application. Om-it...,-$-.0-0)

Audited or Unaudited:

Prepared By:
ASSETS

Cash on Hand and in Banks

LIABILITIES

---------------------

$

Accounts Payable for Merchandis"'
To Banks

Less Reserve for Doubtful Account_ .
Inventories (How valued- Cost D or MarketD )
Finished

------------------

.

$

Notes Payable- Payments Due Within One Year

* Notes Receivable ----------------------------*Accounts Receivable (Trade)
.$

-------------------------------

For Merchandise

-------------------------

To Officers, Directors and Stockholders _ _

$

To Others

__

-------------------------------

Stock in Process-------------

Mortgages Payable- Payments Due Within One Ye r

Raw Material ---------------

Contracts Payable- Payment Due Within One Year _
*Accounts Due Officers or Stockholder

*Other Current Assets --------- --- ·- · ······- ·- --Total Current Assets ------------------Cost
Depr.

Accounts and Notes Due Affiliates ---------------Income Taxes - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - Withholding and Other Taxes

Land
Buildings

*Other Accruals

Mach. & Equip.

*Other Current Liabilities -----------------------$
Total Current Liabilities

F&F
Autos & Trucks

Notes Payable- Payments Due After One Yea_r

Net Fixed Assets (Cost Less Depr.)_ - - - - - -- - - *Due from Affiliates or Subsidiaries ----------------

$

Mortgages Payable- Payments Due After One Year
Contracts Payable- Payments Due After One Yer

* Due from Officers, Directors, and Stockholders

SBA Loan- Payments Due After One Year

Life Insurance (Cash Surrender Value)_
* Other Assets

------------------------------

*Other Liabilities ------------------------------

------------------------- - -- - - - - -

Total Liabilites ----------------------

$

Capital Stock Outstandinq _ _ _ _ _ _ $
$
Earned Surplus
$
Capital Surplus
Total Assets

._ .

Capital Account (If individual or partnership)
Total Liabilities and Net Worth

$

..

$

*ITEMIZE ON A SEPARATE SHEET ALL ITEMS MARKED WITH AN ASTERISK.
Contingent Liabilities: Accounts or notes receivable discounted or sold with endorsement or guarantee and all other contingent liabilities, including terms
of any leases, should be explained on a separate sheet. Also, describe any pending or imminent litigation, claims against U.S. Government or others.
Give present status.
Accounts Receivable

Ageing
Under 30 days

Accounts Payable

$

$

$

$

30- 60 days
60- 90 days
90- 120 days
Over 120 days
Uncollectible
Totals
Contracts, Notes and Mortgages Payable:
To Whom Payable

SBA Form 1531 (09-2014)

Original Amt.

Previous Editions Obsolete

Present
Balance

Rate of
Interest

Monthly
Payment

state Specific Sources for funds to finance this proposed contract:
(Attach letters of credit and/or your personal financial statements, if necessary)

SBA Form 1531 (09-2014)

Previous Editions Obsolete

COMPARATIVE STATEMENTS OF SALES, PROFIT OR LOSS, ETC. Detailed Profit and Loss statements Must Be Attached
Fiscal Year Ends (Give Date):

MM/DD/YY

to date

If a Corporation, Use This Block:
Net Sales (Gross sales less returns and allowances)
Depreciation
Income Taxes
Compensation of Officers (Included in expenses)
Net Profit (After depreciation and Income Taxes)
Dividends Paid

to date

If a Partnership or Proprietorship, Use This Block:

Net Sales (Gross sales less returns and allowances
Depreciation
Withdrawals (For Income Taxes)
Personal Withdrawals by Owner or Partners
Net Profit (After depreciation and withdrawals)
B.

MANAGEMENT

Information to be furnished as to each officer, partner, or proprietor of applicant
Narne

%of Ownership

PART Ill

Net Worth Outside of Applicant

AGREEMENT

In order to comply with the provisions of Section 13, 15 U.S.C 642 of the Small Business Act, the applicant does hereby certify to and agree as follows:
A. In the event SBA issues the Certificate of Competency herein applied for, then for a period of two years from the date upon which such Certificate shall
have been issued, the applicant and his subsidiaries and affiliates agree to refrain from employing, tendering any offer of employment to, or retaining for
professional services, any person who, on such date, or within one year prior thereto, shall have served as an officer, attorney, agent, or employee of
SBA occupying a position or engaging in activities which SBA shall have determined involve discretion with respect to the granting of assistance unde
the above Act
B. The names of all attorneys, accountants, appraisers, engineers, consultants, agents, or other persons engaged by or on behalf of the applicant for the
purpose of expeditino this application or obtainino a Certificate of Competency and the fees and/or other compensation paid to an11 person, are as follows
Name
Occupation
Address (Include Zip Code)
Compensation

C.

The names of any members of the National or District Small Business Advisory Council who have any direct or indirect financial interest whatsoever in
the applicant (such interest to include any direct or indirect financial interest in any other business entity or enterprise which is, in any way, connected
with the undersigned) are to the best of my knowledge, information, and belief as follows:
Name

Address (Include Zip Code)

D.

To notify SBA in writing within five (5) days of any changes in items Band C above.

E.

The applicant further agrees, in order to insure the continued recognition of the integrity of the SBA Certificate of Competency program if the Certificate
of Competency herein applied for is issued,to permit authorized employees or representatives of SBA access to the applicant's financial, production, or
other business records and to the applicant's facilities at all reasonable times during the performance of the contract described in item 8.

F.

That all the statements and all other information set forth in this application and in all exhibits and documents submitted with or in connection with this
application are, to the best of the applicant's information and belief, true and correct and are submitted for the purpose of inducing SBA to grant a
Certificate of Competency to the applicant.

Any documents that you provide as part of this request for a Certificate of Competency, including bid or proposal information or source selection information, are prohibited
from being released prior to the award of a contract. See, FAR § 3.104-3. After award of a contract, all information and/or documents may be disclosed but will be protected
to the fullest extent permitted by law, including the Privacy Act 5 U.S.C. § 552a and Freedom of Information Act, 5 U.S.C. § 552.

SBA Form 1531 (09-2014)

Previous Editions Obsolete

PART IV -Certifications
By signing below, I hereby certify that all statements and all other information set forth on this form, and in all exhibits and documents submitted
with or in connection with this application are complete and accurate. I understand that the SBA is relying on the accuracy of this information in
determining whether to issue the Certificate of Competency (COC) and that issuance of the COC can entitle me and/or my company to obtain
future governmental payments or other benefits. WARNING: Any false information or misrepresentation regarding the accuracy and
completeness of the information provided may result in criminal, civil and/or administrative sanctions including, but not limited to: 1) fines of up to
$500,000 and imprisonment of up to 10 years, or both, under 18 U.S.C. § 1001, as well as penalties under other criminal laws; 2) treble damages
and civil penalties under the False Claims Act, 31 U.S.C. §§ 3729-3733; and 3) suspension and/or debarment from all Federal procurement and
non-procurement transactions.

Date
--------------------------------

Signature
NOTE: Corporate applicants must execute application in corporate name, by duly authorized officer, and partnership applicants must execute
application in firm name, together with signature of a general partner.
Section 16 of the Small Business Act, 15 U.S.C. 645, makes it a criminal offense punishable by fine of not more than $5,000 or by imprisonment for no
more than $5,000 or by imprisonment for not more than two (2) years, or both, to make a statement knowing it to be false or make any
misrepresentation to the Small Business Administration for the purpose of influencing in any way the action of the Administration.
fA.ccording to the paperwork Reduction Act you are not required to respond to this collection of information unless it displays a currently valid OMB ControlNumber. The
number for this collection is 3245-0225. The estimated burden for completing this form, including time for reviewing instructions, gathering data needed,and completing and
reviewing this form is 8 hours per response. Comments or questions on the burden estimates should be sent to U.S. Small Business Administration, Chief,AlB, 409 3rd St.,
SW, Washington DC 20416 and/or SBA Desk officer, Office of Management and Budget, New Executive Office Bldg, Room 10202, Washington DC 20503 PLEASE DO NOT
SUBMIT COMPLETED FORMS TO OMB

SBA Form 1531 (09-2014)

Previous Editions Obsolete