3245-0320 HUBZone Level 1 Program Examination Form and Instructions (1) 11-29-2022

HUBZone Program Examination Response
Instructions:
To complete your submission, an authorized officer of the firm must complete and sign this form and
submit it along with the supporting documentation specified below. Please note that upon reviewing
the submission, SBA may require additional information as part of the program examination. The
definitions for the terms used in this form are set forth in the Small Business Act (15 U.S.C. § 657a), SBA
regulations (13 C.F.R. Part 126), and any other statutory and regulatory provisions referenced in those
authorities

Section A: Firm Information

Complete the table below. Specific instructions for each block are located on page 3. Responses must
be true and correct as of your firm’s most recent certification anniversary date.
1. Firm Name:
2. HUBZone application number:
3. Most recent certification anniversary date:
4. Address of principal office:
5. In the first column, enter the number of locations per type that employees were working from
during the four-week period immediately prior to the certification anniversary date. Note:
there can only be one Principal Office.
In the second column, enter the number of employees who worked more than 50% of their
time from each location during the four-week period immediately prior to the certification
anniversary date. If an employee was teleworking due to COVID-19, allocate him/her to the
location from which he/she would have been working if not for COVID-19.

Location
Principal Office
Other HUBZone location (including standard telework)
Non-HUBZone location (including standard telework)
Job Site

Number of
locations of this
type

Number of
Employees

TOTAL

0

0

6. Number of employees allocated to the principal office that were
teleworking due to COVID-19 during the four-week period immediately
prior to the certification anniversary date.
7. Number of employees residing in a HUBZone (must represent at least
35% of the total number of employees to meet program requirements):

Section B: Supporting documentation
1. HUBZone map of principal office
Follow these steps to obtain the required information:
1. Go to the HUBZone Map.
2. Enter the address of your firm’s principal office into the search bar.
3. You should now be viewing your firm’s HUBZone map. Select the “Printable Version” icon
from the menu on the right to open a PDF of the map.
4. Save the map PDF to your computer; name the file “[Insert Firm Name] HUBZone map” (for
example, “ABC LLC HUBZone map”).
2. Google map of principal office
Follow these steps to obtain the required information:
1. Go to Google maps.
2. Enter the address of your firm’s principal office into the search bar.
3. You should now be viewing your firm’s Google map. In the left panel, click the menu icon (three
horizonal lines) then “Print”. Under “Printer” select “Save as PDF”.
4. Save the map PDF to your computer; name the file “[Insert Firm Name] Google map” (for
example, “ABC LLC Google map”).
Note: If Google maps does not have a photo image of your principal office, take a photo of the
exterior of the building that shows the street number and signage, if it exists, and include it with
your submission.

Signature of authorized officer
Warning: By signing this program examination response you are representing on your own behalf, and
on behalf of the firm, that the information provided in this program examination response and any
document or supplemental information submitted in connection with this program examination
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response, is true and correct as of firm’s most recent recertification date. Any intentional or negligent
misrepresentation of the information contained in this program examination response 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 nonprocurement transactions; and 5) program
termination.
The undersigned has reviewed, verified, and certifies that the information provided in
this response is true and correct.

Signature

Print Name and Title
Note: If you are unable to electronically sign this form, you may print, sign, and scan the form.

Submission Instructions:
Save this completed and signed form to your computer; name the file “[Insert Firm Name] Program
Exam Response Form” (for example, “ABC LLC Program Exam Response Form”).
Email your response within thirty (30) calendar days of receipt to [email protected] with the
subject line “[Insert Firm Name] Program Exam Response” (for example, “ABC LLC Program Exam
Response”). Your email should include three attachments: 1) this completed and signed form, 2) your
HUBZone map and 3) your Google map.

Instructions for Completing Section A: Firm Information
Block 1: Fill in your firm’s name as it appears in sam.gov.
Block 2: This number is located on your firm’s certification letter and other correspondence from the
HUBZone program which can be located in your GLS account.
Block 3: Your firm’s certification date is the date specified in its certification letter which can be
located in your GLS account. If your firm’s certification date was Nov. 1, 2018, your most recert
certification anniversary date is Nov. 1, 2020.
Block 4: “Principal Office” means the location where the greatest number of the concern’s employees
at any one location perform the majority of their work. See 13 C.F.R. § 126.103.
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Block 5: In the first column, enter the number of locations per type that employees were working
from during the four-week period immediately prior to the certification anniversary date. Note: there
can only be one Principal Office.
In the second column, enter the number of employees who worked more than 50% of their time from
each location type during the four-week period immediately prior to the certification anniversary date.
If an employee was teleworking due to COVID-19, allocate him/her to the location from which he/she
would have been working if not for COVID-19.
“Employee” means any individual employed on a full-time, part-time, or other basis, so long as that
individual works a minimum of 40 hours during the four-week period immediately prior to the date of
the firm’s most recent recertification. In general, the following are NOT considered employees: (i)
Volunteers who do not receive compensation for their work; (ii) Individuals who receive deferred
compensation for work performed; (iii) Independent contractors that report income via IRS Form 1099;
and (iv) Subcontractors. See 13 C.F.R. § 126.103.
If an employee works at multiple locations, then the employee will be deemed to work at the location
where the employee spends more than 50% of his or her time. If an employee does not spend more
than 50% of his or her time at any one location and at least one of those locations is a non-HUBZone
location, then the employee will be deemed to work at a non-HUBZone location. See 13 C.F.R. §
126.103.
Block 6: Enter the number of employees allocated to the principal office that were teleworking due to
COVID-19 during the four-week period immediately prior to the certification anniversary date.
Block 7: Enter the number of employees that were residing in a HUBZone as of the certification
anniversary date. At least 35% of the total number of employees must have been residing in a
HUBZone to meet the program eligibility requirements. When determining the percentage of
employees that reside in a HUBZone, if the percentage results in a fraction, SBA rounds to the
nearest whole number. "Reside” means to live at a location full-time and for at least 180 days
immediately prior to the date of recertification. See 13 C.F.R. § 126.103. To verify whether an address
is located in a HUBZone, please see the HUBZone Map.

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