Duluth Transit Authority

DULUTH TRANSIT AUTHORITY Declaration of Certification I. BUSINESS PROFILE

Name of Business: Business Address: City: State: Zip Code: Telephone: Fax: FEIN: Business Owner's Name: Title: Email Address: Percentage (%) of Ownership: Website: Year Established: Other Contact Name: Title: Telephone Number: Email Address: Number of Full Time Employees: Number of Part Time Employees: Dun & Bradstreet Number: Legal Business Structure :

Provide the firm’s annual gross receipts, before deducting expenses for the last three (3) years.

Year: Gross Receipts:

(Gross Receipts) Three Year Average:

I understand that the DTA reserves the right to request U.S. Federal Corporate (or personal) income tax returns confirming gross receipts as well as certificates of incorporation issued by localities and/or states.

Product you sell that are on the DTA’s list

______

______Affiliates to your firm:

An affiliate is an individual or concern that has the power to control the firm, or a concern over which the firm has power to exercise control, including indirectly or through a third-party, considering factors such as ownership, management and previous relationships including contractual relationships as further defined in U.S Small Business Administration (SBA) 13 Code of Federal Regulations (CFR) Subsection(s) 121.103(1)-(6).

List the following for any foreign or domestic affiliate of your firm during the last three (3) calendar years: a.) Name: b.) Date the affiliations began and ended: c.) Number of employees: d.) Percentage (%) of ownership by the affiliate of the firm and/or by the firm of the affiliate: e.) Average gross receipts of the affiliate: f.) FEIN for each affiliate:

A separate sheet may be used to outline other affiliates.

II. NOTARIZED ACKNOWLEDGEMENT AND AFFIRMATION

NOTE: It is the sole responsibility of the signatory to submit an updated "declaration of certification" affidavit every two (2) years from their initial date of submission. All information provided in this declaration will be treated as strictly confidential.

I will submit a revised “Declaration of Certification” affidavit to the Small Business and Local Preference Program with any changes such as: ownership, address, telephone number, fax number, e-mail address, point of contact, etc.. I acknowledge and agree that any misrepresentations on this declaration of certification or in records pertaining to a contract or subcontract with DTA may be grounds for permanent termination of the firm’s business relationship with DTA.

The undersigned does hereby make the following acknowledgement:

I, ______affirm that I am the ______(TITLE) and an authorized agent of ______. I do solemnly declare, under the penalties of perjury, that the contents of this document are true and correct to the best of my knowledge.

III. NOTARY PUBLIC

I, ______, a Notary Public in the State/ Commonwealth of

______do hereby certify that ______, appeared before me and is known to me ( or satisfactorily proven) to be the person whose name is subscribed to within this instrument. Subscribed and sworn before me on the

______day of ______, 20______.

Notary Public ______My Commission Expires: (Seal)