3037-0013 Nonprofit Agency Annual AbilityOne Representations and C

U.S. AbilityOne Commission OMB No. 3037-0013 Expiration Date:

Nonprofit Agency Annual AbilityOne Representations and Certifications (ARC)

Instructions for completing this form:

Nonprofit agencies (NPAs) participating in the AbilityOne Program must complete this form annually to demonstrate meeting the qualification requirements of 41 U.S.C 8501(6)(c) and/or (7)(c) and 51 C.F.R. subparts 51-4.3(a) and (b).

Paperwork Reduction Act - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You are not required to respond to this collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The estimated time for completing this form is 2 hours.

Federal Fiscal Year: [Enter text]

Nonprofit Agency (NPA) Name: [Enter text]

Employer Identification Number: [Enter text]

Mailing Address: [Enter text] Phone Number: [Enter number]

Name and email address of principal officer: [Enter text]

Part I. Summary

ABILITYONE Sales [AutoFill]

ABILITYONE Subcontracted [AutoFill]

ABILITYONE Number of Participating Employees Cumulative [AutoFill]

ABILITYONE Hours Worked by Participating Employees [AutoFill]

ABILITYONE DLH Ratio [AutoFill]

NPA ODLH Ratio [AutoFill]

Part II. Signature Block

Under penalty of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. 18 U.S.C. § 1621 and 28 U.S.C. § 1746.

Signature of NPA’s Principal Officer [Signature] Date [Date]

Declaration of the preparer (other than Principal Officer): I have prepared this return, and it is based on all information of which I have knowledge.

Preparer Information

Preparer’s name: [Open text]

Preparer’s email address and phone number: [Open text]

Preparer’s Signature: [Signature] Date [Date]

Firm Information (if applicable)

Name of Firm and EIN: [Open text]

Firm’s mailing address, email address and phone number: [Open text]

Part III. NPA AbilityOne Program Information

1. AbilityOne Sales

Procurement List Items
1.1 NPA Sales from AbilityOne Products	$ [Number]
1.2 NPA Sales from AbilityOne Services	$ [Number]
1.3 NPA Sales from Military Resale (Direct & Warehouse)	$ [Number]
Total AbilityOne Sales	$ Auto Calculation
Base Supply Centers
1.4 NPA Sales from AbilityOne products	$ [Number]
1.5 Base Supply Centers Total Sales	$ [Number]

2. Total Number of Participating Employees Whose Eligibility was Derived From a Government or Private Source (Select all that apply and enter value)

☐ Medicaid [Enter number]

☐ Social Security [Enter number]

☐ Veterans Benefits Administration [Enter number]

☐ Vocational Rehabilitation Services [Enter number]

☐ Individualized Education Program/504 plan/Services plan [Enter number]

☐ Other State and/or Local Government Disability Services [Enter number]

☐ Private Licensed Professional [Enter number]

3. Employment

ABILITYONE EMPLOYMENT	On Oct. 1	On Sep. 30	Total employed during the year
3.1 Number of Participating Employees	[Number]	[Number]	[Number]
3.2 Number of Non-Participating Employees (individuals without qualifying disability documentation) performing DLH	[Number]	[Number]	[Number]
3.3 Number of employees who self-identify as a person with a disability performing indirect labor	[Number]	[Number]	[Number]

4. Direct Labor Hours (DLH) (Hours should include overtime, vacation, holiday, sick leave) 

ABILITYONE DIRECT LABOR HOURS	PRODUCTS	SERVICES	TOTAL
4.1 Direct labor hours performed by Participating Employee	[Number]	[Number]	Auto Calculation
4.2 Direct labor hours performed by Non- Participating Employees	[Number]	[Number]	Auto Calculation
4.3 Total direct labor hours performed (4.1 + 4.2)	Auto Calculation	Auto Calculation	Auto Calculation
4.4 Percentage of direct labor hours performed by Participating Employees	Auto Calculation %	Auto Calculation %	Auto Calculation %

5. Wages for Employees (Wages include overtime, vacation, holiday, sick leave, and fringe payments)

ABILITYONE WAGES		PRODUCTS	SERVICES		TOTAL
5.1 Wages paid to Participating Employees	$ [Number]			$ [Number]	$ Auto Calculation
5.2 Wages paid to DLH Non-Participating Employees	$ [Number]			$ [Number]	$ Auto Calculation
5.3 Lowest hourly wage paid to Participating Employees	$ [Number]			$ [Number]	N/A
5.4 Highest hourly wage paid to Participating Employees	$ [Number]			$ [Number]	N/A
5.5 Mean hourly wage paid to Participating Employees	$ Auto Calculation			$ Auto Calculation	$ Auto Calculation

6. Select other employment benefits offered to Participating Employees (Select all that apply)

☐ NPA-sponsored Health Insurance

☐ Vacation/Sick/PTO Leave

☐ Retirement plan

☐ Short-term disability

☐ Workers’ compensation

☐ Unemployment compensation

☐ Tuition assistance or other education support

☐ Other [Enter description]

Optional: Benefits narrative may be provided here: [Open text]

7. Participating Employee Career Mobility

7.1 Report Participating Employee mobility outcomes within the NPA.

☐ Lateral Mobility (Labor position change utilizing different skills but not a promotion) [Enter number]

☐ Upward Mobility (Promotion or labor position change resulting in increased wages or benefits)

☐ Not Supervisory [Enter number]

☐ Supervisory [Enter number]

☐ Demotion (Labor position change resulting in decreased wages or benefits) [Enter number]

☐ No Movement [Enter number]

For Employees with No Movement:

☐ Employee stated desire to remain in present position. [Enter number]

☐ Employee expressed concern regarding potential government benefit disqualification as a result of increased wages. [Enter number]

☐ Other [Enter description] [Enter number]

☐ Unknown [Enter number]

7.2 Report Participating Employee mobility outcomes outside the NPA, if known at time of departure.

☐ New employment by Federal/State/Local government [Enter number]

☐ New employment by Federal/State/Local contractor [Enter number]

☒ New employment by For-Profit/Non-Profit Employer [Enter number]

☐ Unknown [Enter number]

8. Subcontracting: NPA as Prime Contractor for Procurement List work

8.1 Is any part of the NPA’s Procurement List project(s) subcontracted? 

[Y/N Choice (If Y, then complete 8.2-8.6. If N, then skip to Part IV)]

8.2 Total value of Procurement List project(s) subcontracted to AbilityOne NPA(s): $ [Enter number]

8.3 Total value of Procurement List project(s) subcontracted to Small Business Entities:

$ [Enter number]

8.4 Total value of Procurement List project(s) subcontracted to Other Than Small Business Entities (includes Non-AbilityOne Nonprofit Organizations and Large Businesses:
$ [Enter number]

8.5 Type of Subcontracting Products/Services Purchased 

[Open text.]

8.6 Non-AbilityOne Subcontractor Category (Select all that apply)

☐ Large Business/Commercial Entities

☐ Nonprofit Organization

☐ SBA - 8(a) Program

☐ SBA - Women-Owned

☐ SBA - Veteran-Owned and/or Service-Disabled Veteran-Owned

☐ SBA - Minority Owned

Part IV. Total NPA Information

1. TOTAL NPA EMPLOYMENT	On Oct 1	On Sep 30	Total employed during the year
1.1 Number of Qualifying Direct Labor Employees	[Number]	[Number]		[Number]
1.2 Number of employees without qualifying disabilities performing DLH	[Number]	[Number]		[Number]

2. NPA OVERALL DIRECT LABOR HOURS	PRODUCTS	SERVICES	TOTAL
2.1 Direct labor hours performed by Qualifying Direct Labor Employees	[Number]	[Number]	Auto Calculation
2.2 Direct labor hours performed by Non-Qualifying Direct Labor Employees	[Number]	[Number]	Auto Calculation
2.3 Total direct labor hours performed (2.1+1.2)	Auto Calculation	Auto Calculation	Auto Calculation
2.4 Percentage of direct labor hours performed by Qualifying Direct Labor Employees	Auto Calculation %	Auto Calculation %	Auto Calculation %

3. VETERANS EMPLOYMENT	TOTAL
3.1 Total Veterans employed on a Procurement List project	[Number]
3.2 Total Veterans employed by the NPA	[Number]
3.3 Total veteran wages	$ [Number]

Part V. Other NPA Questions

1. If applicable, did the NPA submit the IRS Form 990 to the IRS within the last year? [Yes/No/NA] 

If Yes, provide a copy.  [Link to 990 file upload process]

If No, provide explanation. [Open text]

2. 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.

If NPA did receive a financial audit, provide copy of the auditor’s report summary.  [Link to auditor summary report upload process]

If the NPA did not receive a financial audit, provide a statement. [Open text]

3. How many members are on the NPA’s Board at the end of the fiscal year?

[Drop down for number]

4. How many NPA board members voluntarily self-identify as a person with a disability? [ Drop down for number]

5. How many of your Procurement List contract sites are represented by a union/unions?

[Enter number]

6. How many NPA participating employees are members of a union related to the employees’ employment?

[Enter number]

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