SELF-CERTIFICATION FORM

Company Name: Dun & Bradstreet No.

Full Address:
Contact Person / Title:
Phone / Fax / Email:
Website: Federal Tax ID No.
Business Type: Sole Proprietor Partnership LLC Corporation | State / Yr Est:

If you are unsure of your status for the below categories, review Federal Acquisition Regulation 19.7 or 52.219-8.1
If you are unsure of your size, refer to SBA’s website at www.sba.gov/size2 or contact your local SBA office.
Check ALL that apply based on your size:
Small Business Small Disadvantaged Business (self-certify)
Certified by SBA as a HUBZone Small Business Woman Owned Small Business
Veteran Owned Small Business Service Disabled Veteran Owned Small Business
Alaskan Native Corporation Historically Black College/University or Minority Institution
Large Business (including non-profit) Indian Tribe
Other:
Agency & Certification No.3

If you are self-certifying as any type of a Small Business, provide the NAICS code for the work you have been
contracted to perform for Dutra. If you are self-certifying as a Small Disadvantaged Business, provide your primary
NAICS code. For information go to www.census.gov/eos/www/naics/.
NAICS Code4 (required):
Additional NAICS Codes:
Number of Employees5 (required):

Under 15 U.S.C. § 645(d), anyone misrepresenting size status shall (1) be punished by a fine, imprisonment,
or both; (2) be subject to administrative remedies; and (3) be ineligible for participation in programs
conducted under the authority of the Small Business Act.

Signature Printed Name Title Date

*****************INTERNAL USE ONLY ***************** (must match)
NAICS CODE & corresponding SIZE criteria for the effort Dutra is soliciting:
Verified HUBZone status in SAM on: / / . Certified? (Y/N) . Certification date: / /

This form is valid for up to one year. It is your responsibility to notify Dutra if your size or ownership status changes
during this one-year period.
Return Form To: Donna Fraser, SBLO, The Dutra Group, 160 River Road, Building A, Rio Vista, CA 94571,
[email protected]; fax: 707-374-6848; phone: 707-374-0131.

1
https://www.acquisition.gov/far/current/html/Subpart%2019_7.html & http://www.acquisition.gov/far/current/html/52_217_221.html#wp1135900
2
http://www.sba.gov/sites/default/files/files/Size_Standards_Table%281%29.pdf & http://www.sba.gov/size-standards-tool?ms=nid4060
3
http://www.sba.gov/content/register-government-contracting
4 NAICS codes are needed for filing the SSR breakout report (by 3-digit NAICS subsector) that Dutra is required to submit to the
Government annually pursuant to Federal Acquisition Regulation (FAR) 52.219-9(l)(2)(iii).
5
Required because, in accordance with FAR 2.101, a small business for a subcontract valued at $10,000 or less is one with 500 or fewer
employees. For a subcontract valued over $10,000, the size is determined by the NAICS code of the procurement.
MAR 2014 (REV)
DEFINITIONS

SMALL BUSINESS CONCERN: The term “small business concern” shall mean a business as defined pursuant to Section
3 of the Small Business Act and relevant regulations issued pursuant thereto. Generally, this means a small business concern
organized for profit, which is independently owned and operated, is not dominant in the field of operations in which it is
bidding, and meets the size standards as proscribed in Government regulations. Consult your Regional or District SBA
office if further clarification is needed; review FAR 19.7 or 52.219-8 (links provided in footnote 1) or you may also access
information at the Small Business Administration’s website (links provided in footnote 2)

LARGE BUSINESS CONCERN: A business concern that exceeds the small business size code standards established by
the Small Business Administration as set forth in the Code of Federal Regulations, Title 13, Part 121.

SBA 8(a) CERTIFIED: A business concern that has met the certification criteria of the Small Business Administration
pursuant to Section 8(a) of the Small Business Act.

HUBZone CERTIFIED: Must obtain certification from the SBA. A small business concern located in a “historically
underutilized business zone”, is owned and controlled by one or more U.S. Citizens, and at least 35% of its employees
reside in a HUBZone. See the SBA Website at http://www.sba.gov/hubzone

WOMAN-OWNED BUSINESS CONCERN: The term “woman-owned business” is a business that is at least 51% owned
by a woman or women who also control and operate it. “Control” in this context means exercising the power to make policy
decisions. “Operate” in this context means actively involved in the day-to-day management.

SMALL DISADVANTAGED BUSINESS CONCERN: Self-certification from SAM.gov website. A small business
concern (1) which is at least 51% owned by one or more socially and economically disadvantaged individuals, or, in the
case of any publicly owned business at least 51% of the stock is owned by one or more socially and economically
disadvantaged individuals, and (2) whose management and daily business operations are controlled by one or more such
individuals.

VETERAN-OWNED SMALL BUSINESS CONCERN: A small business concern that is at least 51% owned by one or
more veterans (as defined in 38 USC 101(2), or, in the case of any publicly owned business, at least 51% of the stock is
owned by one or more veterans. In addition, one or more veterans must control the management and daily business
operations.

SERVICE-DISABLED VETERAN-OWNED BUSINESS CONCERN: A small business concern that is at least 51%
owned by one or more veterans (as defined in 28 USC 101(16), or, in the case of any publicly owned business, at least 51%
of the stock is owned by one or more service-disabled veterans. In addition, the management and daily business operations
must be controlled by one or more service-disabled veterans. In the case of a permanent or severe disability, the spouse or
caregiver of such a service-disabled veteran may control the management and daily operation.

MINORITY-OWNED BUSINESS CONCERN: The term “minority-owned business” refers to a business that is at least
51% owned by individuals who are members of identified minority groups, and whose management and daily business
operations are controlled by one or more of such individuals. Information on the identified minority groups is available on
the SBA website but generally includes Black Americans, Hispanic Americans, Native Americans, Asian-Pacific
Americans, Subcontinent Asian Americans and others as identified in Section 8(a) of the Small Business Act.

NAICS CODE: The North American Industry Classification System – United States (NAICS) replaces the SIC codes.
NAICS covers new industries that did not exist when the SIC System was established. Information and assistance with
NAICS codes is available at 1-888-75NAICS or at www.census.gov/eos/www//naics