Annual Reps and Certs Form (Old Version)

ANNUAL REPRESENTATIONS AND CERTIFICATIONS FOR
ABILITYONE QUALIFIED NONPROFIT AGENCY

INSTRUCTIONS FOR COMPLETION
Each section of the form is detailed below with the information needed to complete the form correctly as
well as justifications and authorities. The interactive form can be completed in Word and printed with
any necessary attachments; signatures must be original.
DEFINITIONS AND ACRONYMS
Acronym or Term

Definition or Description

AbilityOne
Commission

The Commission’s legal name remains the Committee For Purchase From
People Who are Blind or Severely Disabled. However, since 2006 the
Committee has been operating as the U.S. AbilityOne Commission. This
document uses Commission except for Where the Commission’s legal name
is used and for quotations from the Commission’s regulations.

Central Nonprofit
Agency (CNA)

NIB and SourceAmerica are the two Central Nonprofit Agencies designated
by the U.S. AbilityOne Commission. 41CFR 51-3

Community
Rehabilitation
Program (CRP)

The terminology used in the Rehabilitation Act and by SourceAmerica.
CRPs are organizations that perform services or produce products with
Contracting Activities that require a specific product or service. Term
currently preferred is NPA (Nonprofit Agency).

Direct labor

All work required for preparation, processing, and packing of a commodity or
work directly related to the performance of a service, but not supervision,
administration, inspection or shipping. 41 CFR 51-1.3

Inure

To take effect or to result. The Treasury regulations apply the rule for tax
exempt status to define an organization as “not operated exclusively for one
or more exempt purposes if its net earnings inure in whole or in part to the
benefit of private shareholders or individuals.” 26 C.F.R. § 1.501(c)(3)1(c)(2) (1984).

Javits-Wagner-O'Day
(JWOD) Act

Established an employment program designed to provide job opportunities
for people who are blind or who have other significant disabilities. These
jobs involve the sale of goods or services to the Federal Government. 41
USC 8501-8506.

Material (Section 7.A)

Having influence or effect and goes to the substantial matter at issue. The
Tax Court has revoked tax exempt status where non-profit entities have
never fulfilled “religious, charitable, or educational” purposes required for the
exemption or where the circumstances of the business practice have
materially changed such that the entity no longer meets the tax exempt
criteria.

Military resale
commodities

Commodities on the Procurement List sold for the private, individual use of
authorized patrons of Armed Forces commissaries and exchanges, or like
activities of other Government departments and agencies.

NIB

National Industries for the Blind

Nonprofit Agency
(NPA)

NPA is an alternate term for CRP. NPAs are organizations that perform
services or produce products with Contracting Activities that require a
specific product or service.

Other severely
disabled and severely
disabled individuals
(hereinafter persons
with significant
disabilities)

A person (other than a blind person) who has a significant physical or mental
impairment (a residual, limiting condition resulting from an injury, disease or
congenital defect), which limits the person's functional capabilities (mobility,
communication, self-care, self-direction, work tolerance or work skills) such
that the individual is unable to engage in normal competitive employment
over an extended period of time.
(1) Capability for normal competitive employment shall be determined from
information developed by an ongoing evaluation program conducted by or
for the nonprofit agency and shall include, at a minimum, a preadmission
evaluation and a reevaluation at least annually of each individual's capability
for normal competitive employment.
(2) A person with a significant mental or physical impairment who is able to
engage in normal competitive employment because the impairment has
been overcome or the condition has been substantially corrected is not
“other significantly disabled” within the meaning of the definition.

Participating
nonprofit agency

Qualified nonprofit
agency for the blind
(hereinafter nonprofit
agency for the blind)

Qualified nonprofit
agency for other
severely disabled
(hereinafter nonprofit
agency employing
persons with
significant
disabilities)

A nonprofit agency that has been authorized by the Commission furnish a
commodity or service to the Government under the JWOD Act.
An agency organized under the laws of the United States or of any State,
operated in the interest of blind individuals, and the net income of which
does not inure in whole or in part to the benefit of any shareholder or other
individual; which complies with applicable occupational health and safety
standards prescribed by the Secretary of Labor; and which in furnishing
commodities and services (whether or not the commodities or services are
procured under these regulations) during the fiscal year employs blind
individuals for not less than 75 percent of the work-hours of direct labor
required to furnish such commodities or services.
An agency organized under the laws of the United States or any State,
operating in the interests of persons with significant disabilities who are not
blind, and the net income of which does not inure in whole or in part to the
benefit of any shareholder or other individual; which complies with applicable
occupational health and safety standards prescribed by the Secretary of
Labor; and which in furnishing commodities and services (whether or not the
commodities or services are procured under these regulations) during the
fiscal year employs persons with significant disabilities (including blind) for
not less than 75 percent of the work-hours of direct labor required to furnish
such commodities or services.

Acronym or Term

Service-Disabled
Veteran-Owned Small
Business

Significantly Disabled
individual or persons
with a significant
disability

Definition or Description (continued)
A small business that meets the eligibility requirements established by the
Small Business Administration regulations (13 CFR ¶¶ 125.8-125.13) that
require the business to be owned and controlled by service-disabled
veterans (also known as a Service-Disabled Veteran-Owned SBC) who have
a service-connected disability that has been determined by the VA, in writing,
to be a permanent and total service-connected disability as set forth in 38
CFR 3.340 for purposes of receiving disability compensation or a disability
pension.
A person other than a blind person who has a significant physical or mental
impairment (a residual, limiting condition resulting from an injury, disease or
congenital defect), which so limits the person's functional capabilities
(mobility, communication, self-care, self-direction, work tolerance or work
skills) that the individual is unable to engage in normal competitive
employment over an extended period of time.
(1) Capability for normal competitive employment shall be determined from
information developed by an ongoing evaluation program conducted by or
for the nonprofit agency and shall include, as a minimum, a preadmission
evaluation and a reevaluation at least annually of each individual's capability
for normal competitive employment.
(2) A person with a significant mental or physical impairment who is able to
engage in normal competitive employment because the impairment has
been overcome or the condition has been substantially corrected is not
“other significantly disabled” within the meaning of the definition.
In correspondence and policy, the term “significant disability” is synonymous
with the term “severe disability” as defined in 41 U.S.C. 8501 and the
applicable regulations.
SourceAmerica® is a national nonprofit that creates job opportunities for a
skilled and dedicated workforce: people with significant disabilities.

SourceAmerica

We are the vital link between this exceptional workforce, the network of
community-based nonprofits, and the Federal Government and commercial
companies that need the products and services the nonprofits provide.
SourceAmerica is an AbilityOne authorized enterprise.

Subcontracting

Any acquisition from another source of materials, including raw materials, or
services required by the nonprofit agency(ies) to provide a Procurement List
product or service allocated under the AbilityOne Program.

Veteran

Shall have the same meaning in 38 U.S.C. § 101(2) and means a person
who served in the active military, naval or air service, and who was
discharged or released therefrom under conditions other than dishonorable.

OVERALL – APPENDICES
•

All required Appendices shall be presented in the form of a written narrative, not to exceed 3
pages (per Appendix). Exceptions to this would be Articles of Incorporations, Bylaws, and
Revisions to State or Local State Statutes. The written narrative should be formatted in
accordance with the following guidance:
(a) Font
i.
Use an Arial or Times New Roman typeface, a black font color, and a font size of
12 points or larger. A symbol font may be used to insert Greek letters or special
characters; the font size requirement still applies.
(b) Page Formatting
i.
Specifically identify the Section and Line Item Number (i.e 6.A.2)
ii.
Provide a written narrative explanation, single-sided and single-spaced.
iii.
All appendix narrative explanations should be attached as a single PDF file.

INSTRUCTIONS - SECTIONS 1-5: GENERAL INFORMATION
•

Agency Name: Enter the incorporated name of the nonprofit agency (NPA), as stated in the
organization’s Articles of Incorporation.

•

D-U-N-S Number: Enter the corporation’s Dun & Bradstreet D-U-N-S number. NOTE: The DU-N-S Number is a unique nine-digit number assigned to an entity by Dun & Bradstreet that
identifies business entities on a location-specific basis. If the NPA has multiple D-U-N-S
Numbers, enter all associated D-U-N-S Numbers for the NPA.

•

Mailing Address: Enter the NPA’s mailing address, including street address, city, state and zip
code. NOTE: Do not enter a P.O. Box. The address entered should be the location where the
President/Executive Director’s office is located.

•

Form Completed By: Enter the name of the individual who completed the form.

•

Fiscal Year Ending: Enter the end date of the NPA’s current fiscal year.

INSTRUCTIONS - SECTION 6: ABILITYONE REQUIREMENTS:
•

Lines 6.A-6.L requires the NPA to certify an answer of “Yes”, “No” or “N/A” by marking each
statement with an “☒” as appropriate. If the NPA marks “No” for any of the statements in lines
6.A-6.L, the NPA is required to provide an explanation in the form of an attachment, as
instructed in the form.
NOTE: Additional guidance and clarifications are provided below for “Section 6: AbilityOne
Requirements” statements.

Guidance and Clarifications
• Attached Appendices are to include a proposed corrective action plan for approval by the
Commission or a plan already approved by the Commission. Each Appendix is limited to a
maximum response of three (3) pages.
• Any certification by an NPA of “No” for lines 6.A-6.L means the NPA acknowledges it is not in
compliance with the AbilityOne Program regulations. Non-compliant NPAs may be placed on
probation, which would make the NPA ineligible for new AbilityOne work. While on probation,
the NPA may also be subject to the removal of its authorization to provide a product or service
from the Procurement List or removal from the AbilityOne Program.
NOTE: Commission policy, “51.403, Nonprofit agencies out of compliance with Commission
Regulations,” will govern the process used by the Commission to evaluate non-compliant
NPAs.
INSTRUCTIONS - SECTION 7: NONPROFIT AGENCY REQUIREMENTS:
•

Lines 7.A-7.G requires the NPA to certify an answer of “Yes” or “No” by marking each
statement with an “☒” as appropriate. If the NPA marks an answer in any of the statements in
lines 7.A-7.G requesting an attachment, the NPA is required to provide an explanation in the
form of an attached Appendix for EACH line marked, as instructed in the form.
NOTE: Additional guidance and clarifications are provided below for “Section 7: Nonprofit
Agency Requirements” statements.

Guidance and Clarifications
• Attached Appendices are to include a narrative explanation of the specific situation related to
the “No” answer to a specific statement in lines 7.A-7.G.
• Section 7 consists of seven statements related to the operations of your NPA. A response of
“yes” or “no” does not imply your NPA is not in compliance. Some responses, however, may
be a concern to the Commission about an NPA’s ability to correctly function within the
AbilityOne Program as a Federal Government contractor and may result in requests for
additional information.
INSTRUCTIONS - SECTION 8: ABILITYONE PROGRAM INTEGRITY:
•

Lines 8.A-8.E require the NPA to certify the answer of “Yes” or “No” by marking each statement
with an “☒” as appropriate. If the NPA marks “Yes” for any of the statements in lines 8.A-8.E,
the NPA is required to provide an explanation in the form of an attached Appendix for EACH
line marked “Yes”, as instructed in the form.
NOTE: Additional guidance and clarifications are provided below for “Section 8: AbilityOne
Program Integrity” statements.

Guidance and Clarifications
• Attached Appendices are to include a narrative explanation of the specific situation related to
the “Yes” answer to a specific statement in lines 8.A-8.E.
• Section 8 consists of statements your NPA answered as part of the annual System Award
Management (SAM) certification. As the answers to these questions can result in the removal
of the contract from your NPA, the Commission must know how these questions were
answered by your NPA in the SAM certification.

SECTIONS 9- 14, ANNUAL OPERATIONAL DATA
The following instructions provide directions to properly complete Sections 9-14 of the form. The
information entered by the NPA should be for the fiscal year coming to an end. All questions pertain to
the current, ending Federal fiscal year.
INSTRUCTIONS - SECTION 9: NIB AGENCIES ONLY (DOES NOT APPLY TO SOURCEAMERICA
AGENCIES):
Lines 9.A-9.D require the NPA to certify an answer of “Yes”, “No”, or “N/A” by marking each statement
with an “☒” as appropriate. If the NPA marks “No” for any of the statements in lines 9.A-9.D, the NPA is
required to provide an explanation in the form of an attached Appendix for EACH line marked “No”, as
instructed in the form.
It is suggested that NIB NPAs complete the data entry for Section 9.1 and 9.2 PRIOR to
answering items 9.A-9.D
NOTE: Additional guidance and clarifications are provided below for “Section 9: NIB Agencies Only”
statements.
Direct labor is defined as all hours required for preparation, processing and packaging of a
product or hours directly related to the performance of a service but does not include
9.A
supervision, administration, inspection or shipping. Hours performed by a subcontractor
&
related to providing the product or service are not included. Direct labor hours performed by
9.B
temporary workers are included. Also included are hours paid for vacation, holidays and sick
leave.
The Javits-Wagner-O’Day Act requires nonprofit agencies participating in the AbilityOne
Program to maintain an overall direct labor hour ratio of at least 75%. The Commission allows
9.C
normal rounding procedures, i.e. your agency’s overall direct labor ratio must be higher than
74.50%.
The Javits-Wagner-O’Day Act requires all direct labor hours performed at an NPA be included
in the ratio calculation. This includes all direct labor performed by temporary employees of
9.D
the NPA or employees and/or employees contracted from a temporary employment agency.
Direct labor hours performed by a subcontractor related to providing the product or service are
not included.
9.1 DATA FOR THE TOTAL AGENCY
9.1.A
9.1.B
9.1.C

9.1.D

9.1.E
9.1.F
9.1.G
9.1.H
9.1.I

Enter the total direct labor hours performed by people who are blind for this fiscal year.
Enter the total direct labor hours performed by people who are sighted for this fiscal year.
Enter the sum of lines 9.1.A and 9.1.B to calculate the total of all direct labor performed by the
agency for this fiscal year.
Calculate the percentage of direct labor hours performed by people who are blind on
AbilityOne product and service contracts by dividing line 9.1.A by line 9.1.C.To be in
compliance with statutory requirements, the result must be at least 75%. The Commission
allows normal rounding procedures, i.e. your agency’s overall direct labor ratio must be higher
than 74.50%.
Enter in the appropriate columns the number of people who are blind and performed direct
labor on products and/or service contracts during this fiscal year.
Enter the number of people who are blind and have an additional physical or mental disability
who performed direct labor during this fiscal year.
Enter the sum of lines 9.1.E and 9.1.F
Enter in the appropriate columns the total wages paid to people who are blind performing
direct labor on products and/or service contracts. Include paid vacation, holidays, sick leave
and Service Contract Act fringe benefits paid in cash.
Enter in the appropriate columns the total direct labor hours performed by veterans who are
blind from line 9.1.A.

9.1.J

Enter in the appropriate columns the total veterans who are blind from line 9.1.G
Enter in the appropriate columns the total wages paid to veterans who are blind and
9.1.K
performed direct labor from line 9.1.I. Include paid vacation, holidays, sick leave and Service
Contract Act fringe benefits paid in cash.
9.2 DATA FOR THE ABILITYONE PROGRAM ONLY
Enter in the appropriate columns the direct labor hours paid to all employees who are blind
9.2.A
and performed direct labor on AbilityOne contracts during this fiscal year.
Enter in the appropriate columns the direct labor hours paid to all employees who are sighted
9.2.B
and performed direct labor on AbilityOne contracts during this fiscal year.
Enter the sum of 9.2.A and 9.2.B to calculate the total of all AbilityOne direct labor hours
9.2.C
performed during this fiscal year.
Calculate the percentage of direct labor hours performed by people who are blind on
9.2.D
AbilityOne product and service contracts by dividing line 9.2.A by line 9.2.C.
Enter in the appropriate columns the number of people who are blind only performing direct
9.2.E
labor on products and service contracts.
Enter in the appropriate columns the number of people who are blind and have significant
9.2.F
disabilities performing direct labor on products and service contracts.
9.2.G
Enter the sum of 9.2.E and 9.2.F
Enter in the appropriate columns the total wages paid to employees performing direct labor on
9.2.H
AbilityOne product and service contracts. Include paid vacation, holidays, sick leave and
Service Contract Act fringe benefits paid in cash.
Enter in the appropriate columns the total direct labor hours from 9.2.A performed by veterans
9.2.I
who are blind.
Enter in the appropriate columns the total direct labor hours from 9.2.G performed by veterans
9.2.J
who are blind.
Enter in the appropriate columns the total amount of wages paid to veterans who are blind
9.2.K
and performed direct labor on AbilityOne product and service contracts from line 9.2.I. Include
paid vacation, holidays, sick leave and Service Contract Act fringe benefits paid in cash.
INSTRUCTIONS - SECTION 10: SOURCEAMERICA AGENCIES ONLY (DOES NOT APPLY TO
NIB AGENCIES):
Lines 10.A-10.D requires the NPA to certify an answer of “Yes”, “No”, or “N/A” by marking each
statement with an “☒” as appropriate. If the NPA marks “No” for any of the statements in lines 10.A10.D, the NPA is required to provide an explanation in the form of an attached Appendix for EACH line
marked “No”, as instructed in the form.
It is suggested that SOURCEAMERICA NPAs complete the data entry for Section 10.1 and 10.2
PRIOR to answering items 10.A-10.D
NOTE: Additional guidance and clarifications are provided below for “Section 10: SourceAmerica
Agencies Only” statements.
Direct labor is defined as all hours required for preparation, processing and packaging of a
product or hours directly related to the performance of a service but does not include
10.A
supervision, administration, inspection or shipping. Hours performed by a subcontractor
&
related to providing the product or service are not included. Direct labor hours performed by
10.B
temporary workers are included. Also included are hours paid for vacation, holidays and sick
leave.

The Javits-Wagner-O’Day Act requires nonprofit agencies participating in the AbilityOne
Program to maintain an overall direct labor hours ratio of at least 75%. The Commission
10.C
allows normal rounding procedures, i.e. your agency’s overall direct labor ratio must be higher
than 74.50%.
The Javits-Wagner-O’Day Act requires all direct labor hours performed at a nonprofit agency
be included in the ratio calculation. This includes all direct labor performed by temporary
10.D
employees of the agency or employees and/or employees contracted from a temporary
employment agency. Direct labor hours performed by a subcontractor related to providing the
product or service are not included.
10.1 DATA FOR THE TOTAL AGENCY
Enter the total direct labor hours performed by people who are blind or significantly disabled
10.1.A
for this fiscal year in the appropriate category.
Enter the total direct labor hours performed by people without significant disabilities for this
10.1.B
fiscal year in the appropriate category.
Enter the sum of lines 10.1.A and 10.1.B to calculate the total of all direct labor performed by
10.1.C
the agency for this fiscal year.
Calculate the percentage of direct labor hours performed by people who are blind or
significantly disabled on AbilityOne product and service contracts by dividing line 10.1.A by
10.1.D line 10.1.C.To be in compliance with statutory requirements; the result must be at least 75%.
The Commission allows normal rounding procedures, i.e. your agency’s overall direct labor
ratio must be higher than 74.50%.
Enter in the appropriate columns the number of people who are blind and performed direct
10.1.E
labor on products and/or service contracts during this fiscal year.
Enter in the appropriate columns the total number of people with significant disabilities,
10.1.F including those who are blind, who have performed direct labor hours on Products and or
services during this fiscal year.
Enter in the appropriate columns the total wages paid to people with significant disabilities,
10.1.G including blindness, performing direct labor on product and/or service contracts. Include paid
vacation, holidays, sick leave and Service Contract Act fringe benefits paid in cash.
Enter in the appropriate columns the total direct labor hours performed by veterans who are
10.1.H
blind or have a significant disability.
Enter in the appropriate columns the total number of veterans who are blind or have
10.1.I
significant disabilities included in line 10.1F.
Enter in the appropriate columns the total wages paid to veterans who are blind or have
10.1.J significant disabilities included in line 10.1.I. Include paid vacation, holidays, sick leave and
Service Contract Act fringe benefits paid in cash.
10.2 DATA FOR THE ABILITYONE PROGRAM ONLY
Enter in the appropriate column the total direct labor hours performed by people who are blind
10.2.A
or significantly disabled on AbilityOne contracts during this fiscal year.
Enter in the appropriate column the direct labor hours performed by people without significant
10.2.B
disabilities on AbilityOne contracts during this fiscal year.
The sum of lines 10.2.A and 10.2.B is the total of all AbilityOne direct labor hours performed
10.2.C
during this fiscal year.
Calculate the percentage of direct labor hours performed by people who are blind or
10.2.D significantly disabled on AbilityOne product and service contracts by dividing line 10.2.A by
line 10.2.C.
Enter in the appropriate columns the number of people who have blindness as a disability and
10.2.E
worked on AbilityOne product and/or service contracts during this fiscal year.
Enter the total number of people with significant disabilities, including those who are blind (line
10.2.F
10.2.E), that have worked on AbilityOne products during the last year.
Enter in the appropriate columns the total wages paid to people with significant disabilities
10.2.G who worked on AbilityOne contracts. Include paid vacation, holidays, sick leave and Service
Contract Act fringe benefits paid in cash.
10.2.H Enter in the appropriate columns the total direct labor hours performed by veterans who are

10.2.I
10.2.J

blind or have significant disabilities from line 10.2.A.
Enter in the appropriate columns the total number of veterans, from 10.2.F, who are blind or
have significant disabilities.
Enter the total amount of wages paid to veterans who are blind or have significant disabilities
who performed direct labor on AbilityOne contracts from line 10.2.H. Include paid vacation,
holidays, sick leave and Service Contract Act fringe benefits paid in cash.

INSTRUCTIONS - SECTION 11: INFORMATION ON AGENCY AND ABILITYONE PLACEMENT
AND PROMOTION OF PEOPLE WHO ARE BLIND OR HAVE SIGNIFICANT DISABILITIES:
Enter in the appropriate column the number of people who are blind or have significant
disabilities who were placed into competitive employment as defined by the AbilityOne
Program during this fiscal year.

11.A

NOTE: The number is to be broken down to indicate placement from AbilityOne projects, non
AbilityOne projects and direct placements as well as the Agency total. Placement of an
individual onto an AbilityOne job can only be counted if the individual's hours are not counted
towards the 75% direct labor ratio requirement. It is important to note the definition of
competitive employment used by the Commission: that the individual is capable of obtaining
and maintaining the job without assistance. This means that supported employment positions
are not considered competitive employment. Direct placement means that the Agency placed
an individual into a competitive job, but the individual never performed direct labor at the
Agency.
Enter in the appropriate column the number of people who are blind or have significant
disabilities who were placed into supported employment as defined by the AbilityOne Program
during this fiscal year.

11.B

NOTE: The number is to be broken down to indicate placement from AbilityOne projects and
non AbilityOne projects and direct placements as well as the Agency total. These placements
include all workers who had been placed into positions other than competitive employment.
Placement of an individual onto an AbilityOne job does not count toward this total. Direct
placement means that the Agency placed an individual into a supported job, but the individual
never performed direct labor at the Agency.

11.C

This question seeks information on people who are blind or have significant disabilities who
are working for the NPA, not in supervisory or management positions, (whether in a client or
other employee status) and who were promoted to a new job or workstation within the Agency
that paid increased wages or benefits. This question should not include individuals whose
wages increased due to cost of living raises or productivity increases. Do not include people
who continued to perform the same job but were hired from a client status into a permanent
employee status.

11.D

This question seeks information on people who are blind or have significant disabilities who
are working for the NPA (whether a client or other employee status) and who were promoted
to a new job or workstation within the Agency that paid increased wages or benefits and which
included increased supervisory, management or technical skills. This question should not
include individuals whose wages increased due to cost of living raises or productivity
increases. Do not include people who continued to perform the same job but were hired from
a client status into a permanent employee status.

INSTRUCTIONS - SECTION 12: AGENCY AND ABILITYONE SALES:
AbilityOne sales are broken into three categories: 1) Military Resale; 2) Products; and 3) Services.
Report only the value of those Military Resale items that were produced in the NPA. Services are items
that were added to the Procurement List as services and products are items that were added to the
Procurement List as products. Report on each line (12.A.1 – 12.A.3) the sales from the previous fiscal
year. Line 12.A.4 is the total AbilityOne sales.
12.A.1

Enter dollar value of Military Resale (Direct) sales This dollar value should include both

and Warehouse Sales.

12.A.2

Enter dollar value of AbilityOne Products sales

12.A.3

Enter dollar value of AbilityOne Service sales

12.A.4

Enter total AbilityOne sales. Sum of lines 12.A.1, 12.A.2 and 12.A.3

Direct

Indicate sales by Base Supply Centers to Federal customers. Those agencies that sell directly to Base
Supply Centers should continue to record those sales as AbilityOne sales.
12.B.1

Enter dollar value of Base Supply Center, AbilityOne Products sales

12.B.2

Enter total Base Supply Center sales. This calculation should include dollar value in 12.B.1

Indicate the totals of any Federal sales and/or other agency contract and subcontract work not recorded
as AbilityOne sales or Base Supply Center sales.
12.C

Enter total of Federal sales other than for those set aside under the AbilityOne Program or
Base Supply Center.

12.D

Enter total sales of other agency contract and subcontract work

Total Agency Sales
12.E

Enter total agency sales Sum of lines 12.A.4, 12.B.2, 12.C and 12.D

INSTRUCTIONS - SECTION 13: SUBCONTRACTING / VENDOR ACTIVITY:
Subcontracting values are broken into three categories: 1) Nonprofit Entities; 2) Small Business Entities;
and 3) Large Business/Commercial entities. Report only the total values paid by the NPA to the
subcontractor. The NPA will be prompted for AbilityOne subcontract totals and total agency subcontract
totals throughout Section 13. NPAs should NOT include values paid to vendors or distributors where a
formal subcontract does not exist. Enter the total dollar values paid by the NPA for each subcontract
category identified in lines 13.A-13.D. If unknown, enter “Unknown.” In the appropriate line(s).
Nonprofit Entities
13.A.1

Enter dollar value of subcontracts paid to AbilityOne NPAs through a Procurement List,
mandatory subcontract.

13.A.2

Enter dollar value of subcontracts paid to any other nonprofits (exclude line 13.A.1)

13.A.3

Enter total dollar value of subcontracts paid to nonprofit entities. Sum of lines 13.A.1 and
13.A.2

Small Business Entities
13.B.1

Enter dollar value of subcontracts paid to Women-Owned businesses

13.B.2

Enter dollar value of subcontracts paid to Veteran-Owned and/or Service-Disabled VeteranOwned businesses.

13.B.3

Enter total dollar value of subcontracts paid to all small business entities. Include lines 13.B.1,
13.B.2, and any other type of small business entities

Large Business/Commercial Entities
13.C.1

Enter total dollar value of subcontracts paid to large business/commercial entities

Total Subcontracts
13.D

Enter total dollar values paid to subcontractors. Sum of lines 13.A.3, 13.B.3, and 13.C.1

INSTRUCTIONS - SECTION 14: VETERANS:
Enter total number of veterans who are employed by your agency, regardless of where they
work, or if they are blind or have a significant disability.
14.A

14.B

The VA defines “veterans” as a person who served in the active military, naval, or air service,
and who was discharged or released therefrom under conditions other than dishonorable. (38
U.S.C. § 101(2))
Enter number of veterans with a service connected disability, as determined by the VA, who
are employed by your agency.
Enter number of Wounded Warriors who are employed by your agency, regardless of where
they work, or if they are blind or have a significant disability.
NOTE: Veterans must suffer from wounds, illnesses or injuries incurred in the line of duty after
September 10, 2001 AND receive or expect to receive at least a 30% rating from the Integrated
Disability Evaluation System (IDES) for one of the conditions listed below:

14.C

•
•
•
•
•
•
•
•
•
•
•

Post-traumatic stress (PTS or PTSD)
Severe traumatic brain injury (TBI)
Severe loss of vision/blindness
Severe hearing loss/deafness
Fatal/incurable disease with limited life expectancy
Loss of limb
Spinal cord injury
Permanent disfigurement
Severe burns
Severe paralysis
Receive a 30% rating or greater for one Veterans Affairs Scheduled Rating Decision
(VASRD) as rated by the Physical Evaluation Board (PEB) in any other Special
Category (SPECAT)/ Enabling Care (EC) or combat/combat-related condition OR
receive a combined 50% IDES rating for any other combat/combat-related condition

The information collected by this form is mandatory for the nonprofit Agency to obtain or retain the
benefits of participation in the AbilityOne Program (41 U.S.C. 46-48c, 41 CFR 51); this information is
used to ensure that nonprofit agencies participating in the AbilityOne Program are meeting the
Program’s requirements; comments may be submitted to Edward Yang, Committee for Purchase From
People Who Are Blind or Severely Disabled, Jefferson Plaza 2, Suite 721, 1401 South Clark Street,
Arlington, VA 22202; the estimated burden per respondent is XXX hours and the cost of sending the
form to NIB or SourceAmerica; the OMB approval number is 3037-0013 the expiration date is
XX/XX/201X.

ANNUAL REPRESENTATIONS AND CERTIFICATIONS FOR ABILITYONE
QUALIFIED NONPROFIT AGENCY (NPA) FORM

APPROVED OMB NO.

1. AGENCY NAME

[enter agency name]

[enter D-U-N-S number]

3. MAILING ADDRESS

[enter mailing address]
[enter city]

[enter state]

[enter zip code]

4. FORM COMPLETED BY

[enter POC name]

5. FISCAL YEAR ENDING

[enter month/day/year]

2. D-U-N-S
NUMBER(s)

EXPIRES

THE NPA CERTIFIES THAT THE INFORMATION PROVIDED IN
SECTION 6 – SECTION 14 BELOW IS ACCURATE, COMPLETE, AND CURRENT.
6. ABILITYONE PROGRAM REQUIREMENTS
6.A

In accordance with 41 CFR 51-4.3(a), the NPA complies “with the requirements of
a "nonprofit agency for other significantly disabled" or a "nonprofit agency for the
blind" as defined in 51-1.3."

-6.A.1

In furnishing products or services (whether or not the products or services are
procured under these regulations) during the fiscal year, the NPA “employs blind
individuals and/or individuals with significant disabilities for not less than 75
percent of the work-hours of direct labor required to furnish such products or
services.” (41 CFR 51-4.1.3) NOTE: If the NPA answers “YES” to this statement,
the overall direct labor hour ratio reported in line 9.1.D or line 10.1.D must be not
less than 75%. The Commission allows normal rounding procedures, i.e. your
agency’s overall direct labor ratio must be higher than 74.50%.

-6.A.2

The NPA complies with the requirement to include a statement in its bylaws that
the net income of the NPA “does not inure in whole or in part to the benefit of any
shareholder or other individual.” (41 CFR 51-4.1.3)

6.B

The NPA furnishes "products or services in strict accordance with Government
orders." (41 CFR 51-4.3(b)(1))

6.C

The NPA complies "with the applicable compensation, employment and
occupational health and safety standards prescribed by the Secretary of Labor,
including procedures to encourage filling of vacancies within the nonprofit agency
by promotion of qualified employees who are blind or have other severe
disabilities." (41 CFR 51-4.3(b)(2))

-6.C.1

-6.C.2

The NPA complies with all applicable contract clauses, such as affirmative action,
EEO, FMLA, drug free workplace, Vets-4212 and code of business ethics and
conduct.
The NPA complies with the applicable compensation and employment standards
prescribed by the Secretary of Labor (such as Fair Labor Standards Act, Service
Contract Act and the Davis-Bacon Acts), including procedures to encourage filling
of vacancies within the nonprofit agency by promotion of qualified employees who
are blind or have other significant disabilities.

☐

YES

☐

NO, Attach Explanation:
labeled Attachment 6.A

☐

YES

☐

NO, Attach Explanation:
labeled Attachment 6.A.1

☐

YES

☐

NO, Attach Explanation:
labeled Attachment 6.A.2

☐

YES

☐

NO, Attach Explanation:
labeled Attachment 6.B

☐

YES

☐

NO, Attach Explanation:
labeled Attachment 6.C

☐

YES

☐

NO, Attach Explanation:
labeled Attachment 6.C.1

☐

YES

☐

NO, Attach Explanation:
labeled Attachment 6.C.2

☐

NO, The agency was audited
by DOL. The DOL findings
report is attached: labeled
Attachment 6.C.2

-6.C.3

The NPA complies with applicable Occupational Safety and Health Act
(OSHA) standards as prescribed by the Secretary of Labor. The NPA has, at
a minimum, a hazard safety plan.

☐

YES

☐

NO, Attach Explanation: labeled
Attachment 6.C.3

☐

NO, The agency was inspected
and citations were received, the
inspector’s report is attached:
labeled Attachment 6.C.3

The NPA complies "with directives or requests issued by the Committee in
furtherance of the objectives of the JWOD Act or its implementing
regulations." (41 CFR 51-4.3(b)(3))

☐

YES

6.D

☐

NO, Attach Explanation: labeled
Attachment 6.D

☐

6.E

The NPA makes "its records available for inspection at any reasonable time
to representatives of the Committee or the central nonprofit agency
representing the nonprofit agency." (41 CFR 51-4.3(b)(4)

YES

☐

NO, Attach Explanation: labeled
Attachment 6.E

The NPA maintains "records of direct labor hours performed in the nonprofit
agency by each worker." (41 CFR 51-4.3(b)(5))

☐

6.F

YES

☐

NO, Attach Explanation: labeled
Attachment 6.F

☐

YES

6.G

The NPA maintains "a file for each blind individual performing direct labor,
which contains a written report reflecting visual acuity and field of vision of
each eye, with best correction, signed by a person licensed to make such an
evaluation, or a certification of blindness by a State or local government
entity." (41 CFR 51-4.3(b)(6))

☐

NO, Attach Explanation: labeled
Attachment 6.G

☐

N/A, Individuals who are blind are
NOT served by the NPA.

The NPA maintains "in the file for each blind individual performing direct labor
annual reviews of ability to engage in normal competitive employment. These
reviews must be signed by an individual qualified by training and/or
experience to make this determination." (41 CFR 51-4.3(b)(7))

☐

YES

☐

NO, Attach Explanation: labeled
Attachment 6.H

☐

N/A, Individuals that are blind are
NOT served by the NPA.

☐

YES

☐

NO, Attach Explanation: labeled
Attachment 6.I

☐

N/A, 6.I does not apply to ANY
NIB NPA.

☐

N/A, Individuals with significant
disabilities are NOT served by the
NPA.

☐

YES

☐

NO, Attach Explanation: labeled
Attachment 6.J

6.H

6.I

6.J

6.K

For each individual with a significant disability, the NPA maintains a file that
contains "a written report signed by a licensed physician, psychiatrist or
qualified psychologist, reflecting the nature and extent of the disability or
disabilities that cause such person to qualify as a person with a significant
disability, or a certification of the disability or disabilities by a State or local
governmental entity.” (41 CFR 51-4.3(c)(1))
For each individual with a significant disability the NPA maintains a file that
contains "reports which state whether that individual is capable of engaging in
normal competitive employment. These reports shall be signed by a person or
persons qualified by training and experience to evaluate the work potential,
interests, aptitudes and abilities of persons with disabilities, and shall normally
consist of preadmission evaluations and reevaluations prepared at least
annually." (41 CFR 51-4.3(c)(2))
The NPA maintains "an ongoing placement program operated by or for the
nonprofit agency to include a liaison with appropriate community services
such as the State employment service, employer groups and others. Those
individuals determined capable and desirous of normal competitive
employment shall be assisted in obtaining such employment." (41 CFR 514.3(b)(8))

☐
☐

N/A , 6.j does not apply to ANY
NIB NPA.
N/A, Individuals with significant
disabilities are NOT served by the
NPA.

☐

YES

☐

NO, Attach Explanation: labeled
Attachment 6.K

6.L

Upon receipt of payment by the Government for products or services
furnished under the AbilityOne Program, the NPA pays "to the central
nonprofit agency a fee which meets the requirements of 41 CFR 51-3.5." (41
CFR 51-4.3(b)(9)

☐

YES

☐

NO, Attach Explanation: labeled
Attachment 6.L

☐

YES, Attach explanation: labeled
Attachment 7.A

☐

YES, The change was identified in
project specific certifications for PL
Addition
_______ dated
___________. NOTE: No appendix
required.

☐

NO, A material change did not
occur.

☐

YES, Attach explanation: labeled
7.B for: 1) Date(s) of change:
Article/State Statues and/or
Bylaws/Implementing Regulations;
and 2) Copies of the specific
change(s)

☐

NO, A change did not occur.

☐

YES

☐

NO, Attach explanation: labeled
Attachment 7.C

☐

NO, IRS Form 990 NOT
APPLICABLE to this agency

☐

YES

☐

NO, Attach explanation: labeled
Attachment 7.D

☐

YES

☐

NO, Attach explanation: labeled
Attachment 7.E

7. NONPROFIT AGENCY REQUIREMENTS

7.A

7.B

7.C

Has the NPA had a material change in: 1) corporate structure or leadership
control; or 2) structure at the Board of Directors Officer or Chief Executive
Officer level since the last submitted AbilityOne Annual Representations and
Certifications?

Has the NPA submitted any changes to: 1) the corporate Articles of
Incorporation / State Statues; or 2) the corporate Bylaws/Implementing
Regulations that occurred since the last submitted AbilityOne Annual
Representations and Certifications?

If applicable, did the NPA submit the IRS Form 990 to the IRS within the last
year?

7.D

Did the NPA receive an independent financial audit report for the last year?
NOTE: This can be calendar or fiscal year, depending on the NPA's financial
closing period.

7.E

Does the NPA abide by the AbilityOne licensee agreement?

7.F

Does ANY part of the net income of the nonprofit agency inure to the benefit
of any shareholder or other individual?

☐

YES, Attach explanation: labeled
Attachment 7.F

☐

NO

7.G

Does the NPA comply with cost principles identified in 2 CFR Part 230, Cost
Principles for Non-profit Organizations (formerly OMB Circular A-122)?

☐

YES

☐

NO, Attach explanation: labeled
Attachment 7.G

8. ABILITYONE PROGRAM INTEGRITY

8.A

8.B

8.C

8.D

8.E

Is this entity, or any of its principals, currently debarred, suspended, proposed
for debarment or declared ineligible for the award of contracts by any federal
agency? (FAR 52.209-5, FAR 52.212-3) NOTE: The CNA will check the
exclusions list for the D-U-N-S number(s) of your entity and indicate whether
any exclusion records exist.
In the past three (3) years, has this entity, or any of its principals, been
convicted of or had a civil judgment rendered against them for: commission of
fraud or a criminal offense in connection with obtaining, attempting to obtain,
or performing a public (Federal, State or local) contract or subcontract;
violation of Federal or State antitrust statutes relating to the submission of
offers; or commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, tax evasion, violating
Federal criminal tax laws, or receiving stolen property? (FAR 52.209-5, FAR
52.212-3)

☐

YES, Attach explanation: labeled
Attachment 8.A

☐

NO

☐

YES, Attach explanation: labeled
Attachment 8.B

☐

NO

Is this entity, or any of its principals, presently indicted for, or otherwise
criminally or civilly charged by Government entity with, commission of any of
these offenses enumerated in 8.B? (FAR 52.209-5, FAR 52.212-3)

☐

YES, Attach explanation: labeled
Attachment 8.C

☐

NO

In the past three (3) years, has this entity been notified of any delinquent
Federal taxes in the amount that exceeds $3,000 for which the liability
remains unsatisfied? (FAR 52.209-5, FAR 52.212-3)

☐

YES, Attach explanation: labeled
Attachment 8.D

☐

NO

In the past three (3) years, has this entity had one or more contracts
terminated for default by any Federal agency? (FAR 52.209-5)

☐

YES, Attach explanation: labeled
Attachment 8.E

☐

NO

9. ALL SECTIONS (9, 9.1, AND 9.2), ARE TO BE COMPLETED ONLY BY NIB AGENCIES
☐

YES

9.A

Data in line 9.1.A are the direct labor hours paid to employees of the NPA
who are blind as defined in 41 CFR 51-1.3 of the Commission regulations.
Both sets of hours include vacation, holiday and paid sick leave.

☐

NO, Attach explanation: labeled
Attachment 9.A

9.B

Data in line 9.1.B are the direct labor hours performed by people who are
sighted. Both sets of hours include vacation, holiday and paid sick leave.

☐

YES

☐

NO, Attach explanation: labeled
Attachment 9.B

9.C

The overall direct labor hours ratio reported in line 9.1.D is greater than
74.50%.

☐

YES

☐

NO, Attach explanation: labeled
Attachment 9.C

☐

YES

☐

NO, Attach explanation: labeled
Attachment 9.D

☐

N/A, No temporary individuals or
individuals from temporary
employment agencies provided
direct labor hours.

9.D

Total direct labor hours performed by temporary employees or employees of
temporary employment agencies are included.

9.1 DATA FOR THE TOTAL AGENCY
Direct labor hours performed by people who are blind
Direct labor hours performed by people who are sighted
Total direct labor hours performed (9.1.A + 9.1.B)
Percent of direct labor hours performed by people who are blind
Total number of people who are blind only (regardless of hours
9.1.E
worked)
Total number of people who are blind with other disabilities
9.1.F
(regardless of direct labor hours worked)
Total number of people who are blind performing direct labor
9.1.G
(9.1.E + 9.1.F)
Direct labor wages paid to people who are blind. Include paid
9.1.H
vacation, holidays, sick leave and Service Contract Act fringe
benefits paid in cash.
9.1.I
Direct labor hours performed by veterans included in line 9.1.A
9.1.J
Total number of veterans included in line 9.1.G
Direct labor wages paid to the veterans included in line 9.1.I. Include
9.1.K
paid vacation, holidays, sick leave and Service Contract Act
fringe benefits paid in cash.
9.2 DATA FOR THE ABILITYONE PROGRAM ONLY

PRODUCTS

SERVICES

TOTAL

$

$

$

$

$

$

PRODUCTS

SERVICES

$

$

$

$

$

$

9.1.A
9.1.B
9.1.C
9.1.D

9.2.A
9.2.B
9.2.C
9.2.D
9.2.E
9.2.F
9.2.G
9.2.H
9.2.I
9.2.J
9.2.K

Direct labor hours performed by people who are blind
Direct labor hours performed by people who are sighted
Total direct labor hours performed (9.2.A + 9.2.B)
Percent of direct labor hours performed by people who are blind
Number of people who are blind only (regardless of hours worked)
Number of people who are blind with other disabilities (regardless of
hours worked)
Total number of people who are blind performing direct labor (9.2.E
+ 9.2.F)
AbilityOne direct labor wages paid to people who are blind. Include
paid vacation, holidays, sick leave and Service Contract Act fringe
benefits paid in cash.
Direct labor hours performed by veterans included in line 9.2.A
Total number of veterans included in line 9.2.G
Direct labor wages paid to the veterans included in line 9.2.I. Include
paid vacation, holidays, sick leave and Service Contract Act fringe
benefits paid in cash.

TOTAL

10. ALL SECTIONS (10, 10.1, AND 10.2) ARE TO BE COMPLETED ONLY BY SOURCEAMERICA AGENCIES
10.A

Data in line 10.1.A are the direct labor hours paid to employees of the NPA
who are blind or have other significant disabilities as defined in 41 CFR 511.3 of the Commission regulations. Both sets of hours include vacation,
holiday and paid sick leave.

10.B

Data in line 10.1.B are the direct labor hours performed by people who do not
meet the Commission’s definition of blind or have significant disabilities. Both
sets of hours include vacation, holiday and paid sick leave.

10.C

The overall direct labor hours ratio reported in line 10.1.D is greater than
74.50%.

☐

YES

☐

NO, Attach explanation: labeled
Attachment 10.A

☐

YES

☐

NO, Attach explanation: labeled
Attachment 10.B

☐

YES

☐

NO, Attach explanation: labeled
Attachment 10.C

10.D

Total direct labor hours performed by temporary employees or employees of
temporary employment agencies are included.

10.1 DATA FOR THE TOTAL AGENCY
10.1.A
Direct labor hours performed by people with significant disabilities
Direct labor hours performed by people without significant
10.1.B
disabilities
10.1.C
Total direct labor hours performed (10.1.A + 10.1.B)
Percent of direct labor hours performed by people with significant
10.1.D
disabilities
10.1.E
Total number of people who are blind (regardless of hours worked)
Total number of people with significant disabilities (regardless of
10.1.F
hours worked; include numbers from line 10.1.E)
Direct labor wages paid to people with significant disabilities.
10.1.G
Include paid vacation, holidays, sick leave and Service Contract Act
fringe benefits paid in cash.
10.1.H
Direct labor hours performed by veterans included in line 10.1.A
10.1.I
Total number of veterans included in line 10.1.F
Direct labor wages paid to the veterans in line 10.1.H. Include paid
10.1.J
vacation, holidays, sick leave and Service Contract Act fringe
benefits paid in cash.
10.2 DATA FOR THE ABILITYONE PROGRAM ONLY
10.2.A
10.2.B
10.2.C
10.2.D
10.2.E
10.2.F
10.2.G
10.2.H
10.2.I
10.2.J

Direct labor hours performed by people with significant disabilities
Direct labor hours performed by people without significant
disabilities
Total direct labor hours performed (10.2.A + 10.2.B)
Percent of direct labor hours performed by people with significant
disabilities
Total number of people who are blind (regardless of hours worked)
Total number of people with significant disabilities (regardless of
hours worked; include numbers from line 10.2.E)
AbilityOne direct labor wages paid to people with significant
disabilities. Include paid vacation, holidays, sick leave and Service
Contract Act fringe benefits paid in cash.
Direct labor hours performed by veterans included in line 10.2.A
Total number of veterans included in line 10.2.F
Direct labor wages paid to the veterans in line 10.2.H. Include paid
vacation, holidays, sick leave and Service Contract Act fringe
benefits paid in cash.

☐

YES

☐

NO, Attach explanation: labeled
Attachment 10.D

☐

N/A, No temporary individuals or
individuals from temporary
employment agencies provided
direct labor hours.

PRODUCTS

SERVICES

TOTAL

$

$

$

$

$

$

PRODUCTS

SERVICES

$

$

$

$

$

$

TOTAL

11. INFORMATION ON AGENCY AND ABILITYONE PLACEMENT AND PROMOTION OF PEOPLE WITH
SIGNIFICANT DISABILITIES
ABILITYONE

11.A
11.B
11.C

11.D

NONABILITYONE

Number placed into competitive employment
Number placed into supported employment
Number promoted into a new job, other than
supervisory or management positions, that included
increased wages and/or benefits, not cost of living
raises or productivity increases
Number promoted into a new job requiring
supervisory, management or technical skills, that
included increased wages and/or benefits, not cost
of living raises or productivity increases

DIRECT
PLACEMENT

TOTAL

Not
Applicable
Not
Applicable

12. AGENCY AND ABILITYONE SALES
12.A
-12.A.1
-12.A.2
-12.A.3
-12.A.4
12.B
-12.B.1
-12.B.2
12.C
12.D
12.E

Procurement List Items
NPA Sales of Military Resale (Direct & Warehouse)
NPA Sales of AbilityOne Products
NPA Sales of AbilityOne Services
Base Supply Centers
NPA Sales of AbilityOne products

Total AbilityOne Sales

$
$
$
$

Total Base Supply Centers Sales
Total Other Federal non-AbilityOne Sales
Total Other NPA Sales and Subcontracting
TOTAL AGENCY SALES

$
$
$
$
$

13. SUBCONTRACTING ACTIVITY
Provide the total amount of subcontract dollars paid to each category of subcontractor entity in sections 13.A, 13.B and
13.C. Include ONLY dollar values for entities the NPA holds a valid subcontract with the entity.
13.A
-13.A.1
-13.A.2
-13.A.3
13.B
-13.B.1
-13.B.2
-13.B.3
13.C
-13.C.1

Nonprofit Entities
Total value of subcontract(s) with AbilityOne NPAs
(Procurement List, mandatory subcontracts)
Total value of subcontract(s) with other nonprofits
(excluding AbilityOne mandatory subcontracts)
Total subcontract value with Nonprofit Entities
Small Business Entities
Total value of subcontract(s) with Women-Owned businesses
Total value subcontract(s) with Veteran-Owned businesses and/or
Service-Disabled Veteran-Owned businesses
Total subcontract value with all Small Business Entities (Sum of lines
13.B.1 and 13.B.2 and any other small businesses)
Large Business/Commercial Entities
Total subcontract value with Large Business/Commercial Entities
TOTAL SUBCONTRACTS

ABILITYONE

AGENCY TOTAL
(to include AbilityOne)

$

Not Applicable

$

$

$

$

$

$

$

$

$

$

$
$

$
$

14. VETERANS
The numbers reported for line 14.A, 14.B, and 14.C should include all veterans / Wounded Warriors working at the NPA,
whether working in management, indirect labor categories or already counted in items 9.1 or 10.1.)
14.A
Total number of veterans employed at your NPA, regardless of position
Total number of veterans who have a disability in accordance with VA’s definition of
14.B
disability
14.C
Total number of Wounded Warriors employed at your NPA, regardless of position

THIS IS TO CERTIFY, TO THE BEST OF MY KNOWLEDGE AND BELIEF, THE INFORMATION
AND DATA FROM THE RECORDS OF THE AGENCY SUBMITTED* TO THE COMMISSION
THROUGH THE DESIGNATED CENTRAL NONPROFIT AGENCY IN SUPPORT OF THE
AGENCY’S PARTICIPATION IN THE ABILITYONE PROGRAM FOR FEDERAL FISCAL YEAR
[INSERT YEAR]** ARE ACCURATE, COMPLETE AND CURRENT AS OF [INSERT DATE]***
THE CERTIFICATE DOES NOT CONSTITUTE A REPRESENTATION AS TO THE ACCURACY OF
THE ABILITYONE AGENCY CHIEF EXECUTIVE OFFICER (CEO) / EXECUTIVE DIRECTOR AND
THE BOARD CHAIR OR VICE CHAIR’S JUDGEMENT OF FACTS RECEIVED AFTER THE DATE
OF CERTIFICATION. IT APPLIES TO THE DATA UPON WHICH THE ABILITYONE AGENCY CEO /
EXECUTIVE DIRECTOR AND THE BOARD CHAIR OR VICE CHAIR’S JUDGEMENT WAS BASED.
THE DISTINCTION BETWEEN FACT AND JUDGEMENT SHOULD BE CLEARLY UNDERSTOOD.
IF THE ABILITYONE AGENCY HAD INFORMATION REASONABLY AVAILABLE AT THE TIME OF
CERTIFICATION SHOWING THAT THE CERTIFICATION WAS NOT BASED ON ACCURATE,
COMPLETE AND CURRENT DATA, THE ABILITYONE AGENCY’S RESPONSIBILITY IS NOT
LIMITED BY ANY LACK OF PERSONAL KNOWLEDGE OF THE INFORMATION ON THE PART OF
THE ABILITYONE AGENCY’S CEO / EXECUTIVE DIRECTOR AND BOARD CHAIR OR VICE
CHAIR SIGNING THE CERTIFICATION.
THIS CERTIFICATION CONCERNS A MATTER WITHIN THE JURISDICTION OF AN AGENCY
OF THE UNITED STATES AND THE MAKING OF FALSE, FICTITIOUS OR FRAUDULENT
CERTIFICATION MAY RENDER THE MAKER SUBJECT TO PROSECUTION UNDER TITLE 18
USC 1001.

* In accordance with the guidance and instructions of the Annual Representations and Certifications Form.
** Identify the fiscal year being reported.
*** Insert the day, month and year when the Annual Representations and Certifications Form is accurate, complete and current. This should be no
later than the date of certification by the NPA’s CEO / Executive Director and Board Chair or Vice Chair.

(SIGN)→
SIGNATURE (NPA’s

BOARD CHAIR OR VICE CHAIR)

(mm/dd/year)

(SIGN)→

(mm/dd/year)

DATE

SIGNATURE (NPA’S CEO / EXECUTIVE DIRECTOR)

DATE

NAME:

(PRINT)

NAME:

(PRINT)

TITLE:

(PRINT)

TITLE:

(PRINT)

EMAIL:

(PRINT)