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The undersigned swears/affirms that the foregoing information and statements are true and correct and include all material and information necessary to identify and explain the operations of _____________________________________________________________ as well as the ownership thereof.

(Name of Firm)                               

Further, the undersigned agrees to permit the Agency and/or U.S. Department of Transportation (DOT) as part of this certification process and thereafter to interview owners, principals, officers and employees; and to audit or examine books, records and files of the above firm.  Furthermore, any of the public entities that are part of this agency reserve the right to reevaluate a firm’s eligibility for certification.

If at any time the DOT or the Agency has reason to believe that any person or firm has willfully and knowingly provided incorrect information or made false statement, the Agency may refer the matter to the General Counsel of DOT or take other action.  The General Counsel may initiate debarment procedures in accordance with 41 CFR 1-1.604 and 12-1.062 and /or refer the matter to the Department of Justice under U.S.C. 1001, as the General Counsel deems appropriate.

NOTE:  Under Title 18 U.S.C. Section 1001 and Title 15 U.S.C. Section 645, any person who misrepresents a firm’s status as a small disadvantaged business concern or makes false statements in order to influence the certification process in any way to obtain a government contract, shall be subject to fines of up to $500,000 and imprisonment of up to 10 years, or both.

The burden of proof of control and management of the business is on the applicant.  The Agency reserves the right to request any additional information it deemed necessary to determine if a firm is certifiable.  Failure to cooperate and/or provide requested information within the time specified is grounds for termination of the processing of your application for certification.


Name     Signature


Title         Date

Date ____________ State of _______________ County of_________________

On this day before me appeared (name)__________________________with proper identification, who being duly sworn, did execute the foregoing affidavit and did aver that he or she was properly authorized by (name of firm) ____________________________ to execute this affidavit and did so as his or her free act/deed.


____________________________                    ___________________________

                    Notary Public Commission Expiration

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