Form VA Form 0877 VA Form 0877 VETBIZ VENDOR INFORMATION PAGES VERIFICATION PROGRAM

OMB No. 2900-0675
Respondent Burden: 30 Minutes
Expiration Date: XX-XX-XXXX

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, Service Disabled Veteran or eligible Surviving Spouse) and sign the form. Ownership must
equal 99-100%. VA will not accept applications from owners/stockholders who are not Veterans. DO NOT MAIL, EMAIL or FAX 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 Verification and Evaluation (CVE) personnel to
access and verify their records. CVE will match your information with records maintained by the Veterans Benefits Administration (VBA)
NAME OF COMPANY

NON-VET

SURVIVING
SPOUSE

% OF
OWNER(Mr./Ms., First Name, Middle, Last, Jr./Sr./III) SHIP

SVC. DIS.
VETERAN

VETERAN STATUS
VETERAN

NAME(S) OF EACH
BUSINESS OWNER/STOCKHOLDER/
SURVIVING SPOUSE

DUNS

DBA

SSN/VA FILE NO./CLAIM
NO. FOR VETERAN (S)
VETERANS & SERVICE
DATE OF
DISABLED
BIRTH
VETERANS &
SURVIVING SPOUSE
ONLY
(Skip if Non-Veteran)

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)275 as amended by Public Law 111 (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 38 CFR Part 74 and that the business is controlled by
individuals eligible to participate in the Veteran First Contracting program if I am claiming SDVOSB status. A false statement on any part of this 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 subcontractor or
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 entitled 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, Service Disabled Veteran and surviving spouse 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
Public Law 111 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 30 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
MAR 2015

0877

SUPERSEDES VA FORM 0877, DEC 2010,
WHICH WILL NOT BE USED.

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

VA FORM 0877, MAR 2015, page 2

NON-VET

SURVIVING
SPOUSE

(Mr./Ms., First Name, Middle, Last, Jr./Sr./III)

% OF
OWNERSHIP

SVC. DIS.
VETERAN

NAME(S) OF EACH
BUSINESS OWNER/STOCKHOLDER/
SURVIVING SPOUSE

VETERAN

VETERAN STATUS

SSN/VA FILE NO./CLAIM
NO. FOR VETERAN (S)
VETERANS & SERVICE
DISABLED
DATE OF
VETERANS &
BIRTH
SURVIVING SPOUSE
ONLY
(Skip if Non-Veteran)

SUPERSEDES VA FORM 0877, DEC 2010,
WHICH WILL NOT BE USED.

SIGNATURE OF EACH
BUSINESS OWNER(S)

DATE
SIGNED