Dear Targeted Small Business (TSB) Applicant:

Transcription

1 Dear Targeted Small Business (TSB) Applicant: Thank yu fr yur interest in becming certified as a State f Iwa Targeted Small Business (TSB). TSB Certificatin administered by the Iwa Ecnmic Develpment Authrity (IEDA) is designed t help wmen, minrity persns, individuals with disabilities, and service-cnnected disabled veterans vercme sme f the hurdles in starting and grwing a small business in Iwa. Benefits f becming a Certified TSB include: Exemptin frm cmpetitive bidding requirements fr sales f gds and services t state agencies fr purchases up t $10, hur advance ntice f state prcurement pprtunities t give yu a head start n requests fr qutes and cmpetitive bids. Listing in the Certified TSB Online Directry, a recgnized resurce that is utilized by public and private sectr buyers, and a distinctin that adds value t yur business. Educatin and netwrking pprtunities ffered by ur partners thrughut the state prviding valuable infrmatin and cnnectins t help grw yur business. T receive the benefits abve, yur business must be TSB Certified by the Iwa Ecnmic Develpment Authrity /Iwa Department f Inspectin and Appeals (DIA). Eligibility requirements are set ut at Iwa Cde sectin and include the fllwing: Be lcated in the state f Iwa. Operate fr a prfit. Have an annual grss incme f less than fur millin dllars cmputed as an average f the three preceding fiscal years. (Grss incme means the ttal sales less the cst f gds sld, plus any incme frm investments and frm incidentals r utside peratins r surces.) Be wned, perated, and actively managed by a Targeted Grup Persn (TGP), which is ne r mre wmen, minrity persns, persns with a disability, r service-cnnected disabled veterans. A minrity persn means an individual wh is and African American, Latin, Asian r Pacific Islander, American Indian r Alaskan Native American. Disability means, with respect t an individual, a physical r mental impairment that substantially limits ne r mre f the majr life activities f the individual, a recrd f physical r mental impairment that substantially limits ne r mre f the majr life activities f the individual, r being regarded as an individual with a physical impairment that substantially limits ne r mre f the majr life activities f the individual. A service-cnnected disabled veteran must have a service-cnnected disability that has been determined by the U.S. Department f Veterans Affairs r the U.S. Department f Defense as defined in 38 U.S.C. Sectin 101(16). Applicants als must meet all f the prgram s certificatin eligibility standards fund in 261 Iwa Administrative Cde chapter 52, available nline r by requesting a cpy frm this ffice. Enclsed yu will find a certificatin applicatin with all the necessary instructins. Please fllw the instructins t cmplete the applicatin, prvide the additinal applicable dcumentatin and return it t the fllwing address: Iwa Ecnmic Develpment Authrity Targeted Small Business Prgram 200 East Grand Ave. Des Mines, IA

2 When a certificatin determinatin has been made, yu will be ntified by IEDA. If yu have any questins regarding the certificatin prcess, please feel free t cntact us at Sincerely, Jill Lippinctt, Prject Manager jill.lippinctt@iwaeda.cm

3 Iwa Ecnmic Develpment Authrity/ Iwa Department f Inspectin and Appeals Targeted Small Business Certificatin Applicatin Packet The fllwing applicatin packet is fr certificatin as a Targeted Small Business (TSB) by the Iwa Ecnmic Develpment Authrity (IEDA)/Iwa Department f Inspectins and Appeals (DIA). Please carefully read all materials and the TSB Certificatin Applicatin Instructins prvided belw, and review the list f dcuments yu will need t shw wnership, cntrl, and management f yur business. T simplify the applicatin prcess, please answer all questins n the applicatin. Prcessing time is lnger if yu prvide insufficient r inadequate infrmatin r dcumentatin t demnstrate that yur business meets eligibility standards. Any false infrmatin submitted may result in denial and/r decertificatin. Once cmpleted, return the fllwing t IEDA: All requested dcumentatin. Ntarized Signature Page, fund in Sectin 5, verifying that yu wn, perate, and actively manage mre than 51 percent f yur business. Send all f the abve t: Iwa Ecnmic Develpment Authrity Targeted Small Business Prgram 200 East Grand Ave. Des Mines, IA IEDA will evaluate the infrmatin submitted fr cmpliance with 261 Iwa Administrative Cde chapter 52 Iwa Targeted Small Business Certificatin Prgram. Additinal infrmatin/dcuments will be requested if needed. TARGETED SMALL BUSINESS APPLICATION 3

4 TSB Certificatin Applicatin Instructins Sectin 1: Business Prfile - Enter the full legal names fr the Business and Owner(s). Please prvide the address f the business and indicate whether this is als yur hme address. If yur business des nt have a Federal ID number, please prvide yur Scial Security number. Specify yur business structure. Sectin 2: Owner Infrmatin - Targeted Grup Persn (TGP) status. List all additinal wners, their percentage f wnership and their TGP status if applicable. In rder t qualify as a TSB, 51% f the wners f the business must qualify as TGP(s). Sectin 3: Business Operatins - This sectin prvides IEDA/DIA with specific backgrund regarding the wnership f yur business and helps t verify yur wnership status. Please als prvide infrmatin abut the industry yur business is in, its prducts, custmers, and services/benefits that it prvides. This infrmatin will be included in the TSB Online Directry and helps t create an verall picture f yur business fr further prcurement purpses. If yu have business incme, please prvide the grss incme fr the last three years yu have been in business. Please prvide the ttal number f emplyees, including yurself. If licenses are required fr yu t d business, please list the names, including yurself, f the individuals wh hld the licenses t perfrm the wrk required f yur business. List all Members f yur Bard f Directrs/Officers, if applicable. If any Members r Officers f yur Bard are als TGP(s), prvide the basis fr stating that he/she/they is/are TGP(s). If needed, prvide an additinal sheet f paper t list all Bard Members. In rder t qualify as a TSB, 51% f the membership f yur Bard must als qualify as TGP(s). Sectin 4: Dcument List - All applicants are required t submit the dcuments listed under the Dcuments fr All Applicants sectin, additinal dcumentatin based n business type, and prf f Targeted Grup Status. Sectin 5: Signature Page - Please read the Affirmatin and Authrizatin sectin clsely. T be valid, this dcument must be signed befre a ntary. TARGETED SMALL BUSINESS APPLICATION 4

5 TARGETED SMALL BUSINESS CERTIFICATION APPLICATION If yur business is recently established, insert n/a in the space prvided fr questins that d nt apply r pending regarding dcuments fr which yu have applied r will apply. Business Name: SECTION 1: BUSINESS PROFILE Business Address: City: State: Zip: Business address is als the hme address Yes N Phne: TDD Number (hearing impaired nly): Website: Federal ID Number (EIN). If nne, prvide wner s scial security number: Date business was started, will start, r when yu acquired wnership: Sle prprietrship Partnership S Crp C Crp Limited Liability Partnership Limited Liability C. Owner(s) First Name: SECTION 2: OWNER INFORMATION Owner(s) Last Name: Owner(s) SSN: Business Title: President Vice President Treasurer Secretary Percentage f Applicant s wnership f the business: Applying as a: Minrity Persn Wman Persn with a Disability Service- Cnnected Disabled Veteran If applying as a minrity persn, as defined by Iwa Cde sectin b.(3) f which grup d yu cnsider yurself a member? African American Latin Asian r Pacific Islander American Indian Alaskan Native American

6 IOWA ECONOMIC DEVELOPMENT AUTHORITY Additinal Owner Infrmatin (Attach additinal sheets if necessary) In rder t qualify as a TSB, 51% f the wners f the business must als qualify as TGP(s). First Name: Business Title: Last Name: Percentage Owned: SSN: Targeted Grup Persn status (if applicable): Minrity Persn Wman Persn with a Disability Service-Cnnected Disabled Veteran First Name: Business Title: Last Name: Percentage Owned: SSN: Targeted Grup Persn status (if applicable): Minrity Persn Wman Persn with a Disability Service-Cnnected Disabled Veteran First Name: Business Title: Last Name: Percentage Owned: SSN: Targeted Grup Persn status (if applicable): Minrity Persn Wman Persn with a Disability Service-Cnnected Disabled Veteran First Name: Business Title: Last Name: Percentage Owned: SSN: Targeted Grup Persn status (if applicable): Minrity Persn Wman Persn with a Disability Service-Cnnected Disabled Veteran SECTION 3: BUSINESS OPERATIONS Hw did yu acquire yur (at least) 51% wnership f the business? (Did yu purchase the business, btain a lan, r ther?) D yu have any business debt? If s, list the type f debt and the names f all individuals wh share the debt with yu. Select the mst applicable industry fr yur type f business: Manufacturer Dealer with Inventry Dealer withut Inventry Cnstructin Distributr Service Research Cnsultant Retail If yu knw yur Nrth American Industry Classificatin System (NAICS) cde, please prvide it: If yu knw yur Natinal Institute f Gvernmental Prcurement (NIGP) cde, please prvide it: Answers t the fllwing three fields will determine yur rganizatin descriptin in the TSB Directry. Please be as detailed as pssible. Describe the prducts/services yur business makes/ffers t custmers: Wh are yur targeted custmers? What sets yu apart frm yur cmpetitrs? TARGETED SMALL BUSINESS APPLICATION 6

7 IOWA ECONOMIC DEVELOPMENT AUTHORITY If yu have business incme, please prvide yur Grss Incme fr the last three years yu have been in business: 20 Grss Incme: 20 Grss Incme: 20 Grss Incme: (Grss incme means yur annual ttal sales minus the csts f gds sld, plus any incme frm investments, incidentals r utside surces.) 491 IAC 25.1(73) Number f emplyees, including yurself: If licenses are required t d business, prvide the names f the peple wh hld the required licenses. Attach additinal sheets if necessary: Name: License: Name: License: Name: License: If yu have a Bard f Directrs/Officers, prvide the names f all Directrs/Officers and Targeted Grup Status, if applicable. Attach additinal sheets if necessary. In rder t qualify as a TSB, 51% f yur Bard Members must be Targeted Grup Persns. Bard Member Name: Title: Bard Member Name: Title: Bard Member Name: Title: Bard Member Name: Title: Targeted Grup Persn? Yes Targeted Grup Persn? Yes Targeted Grup Persn? Yes Targeted Grup Persn? Yes N N N N Date f mst recent bard reprt filed with the Secretary f State: Once cmplete, please mail r deliver yur applicatin, including the Signature Page fund in Sectin 5 and all applicable dcumentatin t: Iwa Ecnmic Develpment Authrity Targeted Small Business Prgram 200 E. Grand Avenue Des Mines, IA TARGETED SMALL BUSINESS APPLICATION 7

8 IOWA ECONOMIC DEVELOPMENT AUTHORITY SECTION 4: DOCUMENT LIST Dcuments fr All Applicants: Registratin f business name: Cunty Recrder r Secretary f State Prf f TGP status (See list belw) Tw years f business tax returns r individual tax returns and IRS letter verifying yur businesses Federal ID number if yu d nt have business tax returns Prf f liability insurance and Wrkers Cmpensatin insurance, if applicable Cpy f each and every license, registratin, and permit required fr business Purchase agreement, if the business was acquired within the last five years Signed and ntarized applicatin Additinal Dcuments fr LLC Applicants Certificate r Articles f Organizatin Operating Agreement, if mre than ne Member/Manager Additinal Dcuments fr Partnership Applicants Partnership Agreement Additinal Dcuments fr Crpratin Applicants Prf f capital cntributin frm each wner (if the business was started/acquired within the last five years) Bylaws and Articles f Incrpratin, including yur crprate brrwing reslutin Meeting Minutes reflecting electin f current Directrs/Officers Stck ledger, if applicable Prf f TGP status fr Bard f Directrs/Officers. See list f acceptable prf belw. Targeted Grup Persn (TGP) Status Frms: If yu are applying as a minrity persn r as a wman, please prvide dcumentatin f yur status. Acceptable dcumentatin includes a driver s license, passprt, tribal recrd, birth certificate r ther dcumentatin If yu are applying as a persn with a disability r have a physical r mental impairment that substantially limits ne r mre majr life activities, please prvide written verificatin frm ne f the fllwing entities: Iwa Department f Educatin Divisin f Vcatinal Rehabilitatin Iwa Department fr the Blind A licensed medical physician. The physician must cmplete and sign the Verificatin f Disability frm included in the applicatin packet. If yu are applying as a Service-Cnnected Disabled Veteran, please prvide dcumentatin frm the U.S. Department f Veterans Affairs r the U.S. Department f Defense cnfirming that yur disability is service cnnected and the extent f the disability. TARGETED SMALL BUSINESS APPLICATION 8

9 IOWA ECONOMIC DEVELOPMENT AUTHORITY Affirmatin and Authrizatin SECTION 5: SIGNATURE PAGE Fr the purpses f TSB certificatin, I understand that the Iwa Ecnmic Develpment Authrity (IEDA) may request ther infrmatin and/r dcumentatin at any time. If any purchasing authrity fr a department r an agency f state gvernment has reasn t believe that any persn r firm has willfully and knwingly prvided incrrect infrmatin r made false statements, that infrmatin may be cnsidered a material misrepresentatin and may be grunds fr terminating any cntract awarded and fr initiating criminal actin under state laws cncerning false statements r breach f cntract, r bth. I certify that the infrmatin cntained in this applicatin fr Targeted Small Business (TSB) Certificatin status is crrect. I understand that misrepresentatin may be cause fr remval frm the qualified vendr list and may result in ther penalties allwed by law. I affirm that the emplyment practices f the applicant cmpany d nt discriminate n the basis f age, race, creed, clr, sex, natinal rigin r disability. Please be aware f the fllwing regarding fraudulent practices in cnnectin with the Targeted Small Business prgrams. 481 IAC25.10(714) Fraudulent practices in cnnectin with targeted small business prgrams. A vilatin under this is grunds fr decertificatin f the TSB cnnected with the vilatin. Decertificatin shall be in additin t any penalty therwise authrized by this chapter. A persn is may be engaging a fraudulent practice if the persn; 1. Knwingly transfers r assigns assets, wnership r equitable interest in prperty f a business t a Targeted Grup Persn primarily fr the purpse f btaining benefits under a TSB prgram if the transferr wuld therwise nt be qualified fr such prgrams. 2. Slicits and is awarded a state cntract n behalf f a TSB fr the purpse f transferring the cntract t smene wh is nt TSB certified. 3. Knwingly falsifies infrmatin n an applicatin fr the purpse f btaining benefits under TSB prgrams. IEDA may investigate allegatins r cmplaints f fraudulent practices and may take actin t decertify a TSB if it is determined that a vilatin has ccurred. Decertificatin may be appealed. I have read and understand all f the abve. Date Signature f Applicant Subscribed and swrn t befre me this day f 20 My cmmissin expires: Ntary Public Authrizatin t Obtain Infrmatin: I authrize the fllwing entities t prvide infrmatin needed by IEDA t evaluate my qualificatins fr certificatin as a Targeted Grup Persn. This authrizatin s autmatic expiratin date will be ne year frm the date f my signature. Department f Inspectins and Appeals Department f Educatin Veteran s Administratin Department f the Blind Department f Transprtatin TARGETED SMALL BUSINESS APPLICATION 9

10 IOWA ECONOMIC DEVELOPMENT AUTHORITY Iwa Ecnmic Develpment Authrity/ Iwa Department f Inspectins and Appeals Targeted Small Business Prgram Certificatin Applicatin Packet Verificatin f Disability (if applicable) Persns with disabilities seeking certificatin as a Targeted Small Business (TSB) must meet the criteria in respect t business wnership and management. In additin, a licensed health care prvider must certify that the individual named belw is a persn with a disability as that term is defined: "Disability" means, with respect t an individual, a physical r mental impairment that substantially limits ne r mre f the majr life activities f the individual, a recrd f physical r mental impairment that substantially limits ne r mre f the majr life activities f the individual, r being regarded as an individual with a physical r mental impairment that substantially limits ne r mre f the majr life activities f the individual. "Disability" des nt include any f the fllwing: 1. Hmsexuality r bisexuality 2. Transvestitism, transsexualism, pedphilia, exhibitinism, vyeurism, gender identity disrder nt resulting frm physical impairments, r ther sexual behavir disrders. 3. Cmpulsive gambling, kleptmania, r pyrmania. 4. Psychactive substance abuse disrders resulting frm current illegal use f drugs Iwa Cde sectin b.(1) Physician s Statement Individual s Name: Scial Security Number: Date f Birth: Disability (1) (2) (3) Functinal Limitatin (Check all apprpriate) Walking Hearing Speaking Seeing Self Care Breathing Learning Wrking Perfrming Manual Other Tasks (explain belw) Explanatin f Other: Signature f Certifying Health Care Prvider: Prfessinal License Number: State f Issue: TARGETED SMALL BUSINESS APPLICATION 10