AFFIDAVIT OF CERTIFICATION BY SMALL LOCAL ... - WMATA.com

AFFIDAVIT OF CERTIFICATION BY SMALL LOCAL (DC, MD or VA) BUSINESS FORWASHINGTON METROPOLITAN AREA TRANSIT AUTHORITY (the Authority)SMALL LOCAL BUSINESS PROGRAMThis affidavit must be signed before a Notary PublicI, (print full name, “Authorized Representative”), swear or affirmthat I am(title) of applicant firm_______________(firm name, “Firm”), with principal place of business in DC, MD or VA: __________________,and incorporated, if applicable, in the state of______, EIN______________, that allinformation in this affidavit and submitted in the Vendor Registration System is true and that Iam authorized to complete this affidavit on behalf of the Firm.In the space below, list the number of persons employed by the Firm on a full-time, part-timeor other basis (e.g. temporary), but not including volunteers, during each pay period for eachof the preceding completed twelve (12) months, or if the Firm has not been in businesstwelve (12) months, the number of months the Firm has been in business:Provide the Firm’s average gross receipts—meaning the total or gross income of the Firmplus the costs of goods sold by the Firm, as reported to the IRS for the last three (3) calendaryears: $________________In the space below, list the following for any foreign or domestic affiliate of the Firm during thelast three (3) calendar years: 1. name of the affiliate; 2. date the affiliation began and ended;3. number of persons employed by the affiliate (as defined above); 4. percent ownership bythe affiliate of the Firm and/or by the Firm of the affiliate; 5. average gross receipts of theaffiliate (as defined above), and 6. EIN for each affiliate. An affiliate is an individual orconcern that has the power to control the Firm, or a concern over which the Firm has powerto exercise control, including indirectly or through a third-party, considering factors such asownership, management and previous relationships including contractual relationships andas further defined in 13 C.F.R. §121.103:No affiliates.

AFFIDAVIT OF CERTIFICATION BY SMALL BUSINESS page 2Firm Name:____________________________________List up to ten Authority Material Category Codes that represent the primary goods andservices your company sells (include the Authority alpha-numeric code and itscorresponding descriptive title, in words). The list can be found in Step 7 Categorizationof the vendor registration process or athttp://www.wmata.com/bus2bus/bidder_vendor/default.cfm1. 6.2. 7.3. 8.4. 9.5. 10.I understand that the Authority reserves the right to ask for tax records confirming grossreceipts at any time as well as certificates of incorporation issued by state or locality and thatthe information provided in this Affidavit will be kept confidential by the Authority.I agree to update my registration and location information in the Authority’s VendorRegistration System within thirty (30) calendar days of any such change (e.g., ownership,address, telephone number, e-mail address, etc).I acknowledge and agree that any misrepresentations in the Vendor Registration System oron this form or in records pertaining to a contract or subcontract with the Authority may begrounds for permanently terminating my business relationship with WMATA.Agreed to and Affirmed:_____________________ __________ _______ _____ (_ )_____ _Signature of Authorized Date E-mail Address Telephone NumberRepresentativeNOTARIZATIONI, _________________________________, a Notary Public in the____________________do hereby certify that_____________________________________,appeared before me and is known to me (or satisfactorily proven) to be the person whosename is subscribed to within this instrument. Subscribed and sworn before me this ____ dayof __________, 200__,SealNotary Public _ _ My Commission Expires on:This form shall be signed and returned by no later than December 31 st of every year to:Coordinator, Small Local Business Program, Office of Procurement and Materials, WashingtonMetropolitan Area Transit Authority, 600 Fifth Street, NW, Room 3B, Washington, DC 20001