Page 1 of 3
TMLS 5-2599A (12/2014)
PLEASE ASSURE ALL INFORMATION IS CURRENT AND ACCURATE
Vendor Name:
Vendor Address:
E-Mail Address:
Vendor Number:
Website:
Duns Number:
Textron Systems Marine & Land Systems, 1010 Gause Blvd., Slidell, LA 70458. Mr. Roger Worrill: P 985-661-3839, F 985-661-2288 rworrill@tmls.textron.com
Subject: Government Procurement Related Certifications
In accordance with Government regulations and prime contract requirements, Textron Systems Marine & Land Systems is required to annually verify the business size of
our suppliers/subcontractors and to validate compliance with Government statutes dealing with Equal Opportunity practices, Small Business concerns and reporting of labor
disputes. In this regard, you are requested to completely execute BOTH PAGES of this form and return it to the attention of the appropriate contact noted above. Or you
may contact the Small Business Administration Home Page at http://www.sbaonline.sba.gov/
NAME OF PARENT COMPANY AND ADDRESS:
SMALL DISADVANTAGED BUSINESS (SDB):
YES
NO
HUBZone
NO. EMPLOYEES:
NO
3
Individual
Joint Venture
Partnership
Corporation
YES
VETERAN
YES
6
NO
NO
SERVICE - DISABLED VETERAN
8
YES
2
4
CAGE CODE:
5
CERT. DATE:
BUSINESS SIZE and TYPE
LARGE
SMALL
NAICS CODE:
WOMEN OWNED
YES
1
FOREIGN OWNED
YES
NO
7
IF FOREIGN, NAME OF COUNTRY
NO
1.
NO. EMPLOYEES: The total of all employees located in all divisions, affiliates, subsidiaries and the parent company.
2.
BUSINESS SIZE: The size standard for a business is established by the U.S. Government’s NAICS Code (North American Industry Classification System). Refer to
FAR 19.001, 19.102 or consult your region’s Small Business Administration Office.
Reference site: http://www.census.gov/epcd/www/naics.html
NOTICE: Any person who misrepresents a firm’s size and/or status for the purpose of obtaining a contract may be punished by a fine or by imprisonment or both.
(FAR 52.219-1)
3.
SMALL DISADVANTAGED BUSINESS: A concern that meets the Small Disadvantaged Business requirements consistent with 13 CFR 124, and:
(A) Where the concern is owned by one or more disadvantaged individuals, the net worth of each individual does not exceed $750,000 after taking into account the
applicable exclusions set forth at 13 CFR 124, and
(B) It is identified, on the date of this representation, as a small disadvantaged business concern in the System for Award Management (SAM) database
Reference site: http://dsbs.sba.gov/dsbs/dsp_dsbs.cfm
Note: At least 51 percent of the concern shall be unconditionally owned, controlled, and operated by socially and economically disadvantaged individuals, as defined by the
Small Business Act.
4.
NAICS & CAGE CODE: Provide the primary NAICS Code assigned to your company. Also provide CAGE CODE or mark N/A if none.
Reference sites: NAICS: www.naics.com/search.htm
5.
CAGE CODE: http://www.dlis.dla.mil/cage_welcome.asp
HUBZone: If a small business, indicate whether your company is certified and appears on the List of HUBZone Small Business Concerns maintained by the Small
Business Administration.
Reference site: http://dsbs.sba.gov/dsbs/dsp_dsbs.cfm
6.
WOMEN OWNED: At least 51 percent of the concern is owned by one or more women or in the case of a publicly owned business, at least 51 percent of the stock is
owned by women and one or more women manage and control the daily operation of the business.
7.
FOREIGN OWNED: Any concern whose principal base of operations is located outside the 50 United States, its territories and possessions.
Note: If Foreign fill in bottom of box 7 above.
8.
VETERAN- Means a small business concern per Public Law 106-50.
SERVICE - DISABLED VETERAN - OWNED SMALL BUSINESS (SDVOSB) - means a small business concern per Public Law 106-50.
TOTAL SALES OR RECEIPTS: For the past fiscal year:
___
Note: References to FAR may be viewed on line at: http://farsite.hill.af.mil/
MARINE & LAND SYSTEMS
Page 2 of 3
TMLS 5-2599A (12/2014)
SYSTEM FOR AWARD MANAGEMENT (SAM) DATABASE: Is your Company registered in the US Government’s SAM database? Yes
No
PREVIOUS CONTRACTS AND COMPLIANCE REPORTS (FAR 52.222-22)
(a) It
has,
has not participated in a previous contract or subcontract subject to the Equal Opportunity clause. FAR 52.222-26 is applicable when during a
12-month period the subcontractor has been awarded subcontracts that have a cumulative value in excess of $10,000.
(b) It
has,
1)
2)
has not filed all required compliance reports.
EE0-1 Report is applicable when subcontractor employs 100 or more employees or employs 50 or more employees and has Federal
contracts I subcontracts totaling more than $50,000.
Not Applicable For more information, access the EEOC home page at http://www.eeoc.gov
VETS-100 report is applicable when the subcontractor receives a contract/subcontract in the amount of $100,000 or more (regardless of number of
employees).
Not Applicable: For additional information or filing on line, access VETS http://www.doleta.gov/grants/forms/vets100.pdf
AFFIRMATION ACTION COMPLIANCE (FAR 52.222-25)
Note: Not applicable if business has less than 50 employees.
The Offeror represents that
(a) It
has developed and has on file,
has not developed and does not have on file, at each establishment, affirmative action programs required by the rules and
regulations of the Secretary of Labor (41 CFR 60-1 and 60-2), (or)
(b) It
has not previously had contracts subject to the written affirmative action programs requirement of the rules and regulations of the Secretary of Labor.
PROHIBITION OF SEGREGATED FACILITIES (FAR 52.222-21)
By the submission of this offer, the Offeror certifies that it does not and will not maintain or provide for its employees any segregated facilities at any of its establishments,
and that it does not and will not permit its employees to perform their services at any location under its control where segregated facilities are maintained. The Offeror agrees
that a breach of this certification is a violation of the Equal Opportunity clause in the contract. The Offeror further agrees that (except where it has obtained identical
certifications from proposed subcontractors for specific time periods) it will - (1) Obtain identical certifications from proposed subcontractors before the award of
subcontracts under which the subcontractor will be subject to the Equal Opportunity clause; (2) Retain the certifications in the files; and (3) Forward the following notice to
the proposed subcontractors (except if the proposed subcontractors have submitted identical certifications for specific time periods):
NOTICE TO PROSPECTIVE SUBCONTRACTORS OF REQUIREMENT FOR CERTIFICATIONS OF NONSEGREGATED FACILITIES.
A Certification of Nonsegregated Facilities must be submitted before the award of a subcontract under which the subcontractor will be subject to the Equal Opportunity
clause. The certification may be submitted either for each subcontract or for all subcontracts during a period.
ANTI-KICKBACK ACT (FAR 52.203-7 )
Seller represents by signing below, that s/he will not violate the Anti-Kickback Act of 1986 which prohibits any person from providing or attempting to provide or offering
to provide any kickback in any form.
CERTIFICATION AND DISCLOSURE REGARDING PAYMENTS TO INFLUENCE CERTAIN FEDERAL TRANSACTIONS (FAR 52.203-11) AND
LIMITATION ON PAYMENTS TO INFLUENCE CERTAIN FEDERAL TRANSACTIONS (FAR 52.203-12)
The Offeror, by signing below, hereby certifies to the best of its knowledge and belief that no Federal appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of
Congress on its behalf in connection with the awarding or modification of a subcontract.
NOTICE TO GOVERNMENT OF LABOR DISPUTES - In accordance with FAR 52.222-1 entitled “Notice to Government of Labor Disputes,” please complete the
following information
.
Is your Plant/Facility: Union
Non-Union
Current Labor Agreement(s) Expires: __
_________
Union Affiliate(s): _
CERTIFICATION OF CONTRACTOR CODE OF BUSINESS CONDUCT & ETHICS DISCLOSURE OF VIOLATIONS (FAR 52.203-13)
The Offeror represents that:
it has, or
it does not have, a Code of Business Conduct and Ethics applicable to all employees.
(Note: This requirement is FAR mandatory for any orders or modifications to orders that cause a purchase order or subcontract to exceed a total value of $5 million dollars.)
For questions or concerns regarding Textron’s Business Conduct Guidelines, please go to www.textron.com, to view Textron's Policy and to obtain contact information.
DEBARMENT CERTIFICATION - FAR 52.209-5 Certification Regarding Responsibility Matters, FAR 52.209-6 Protecting the Government's Interest
When Subcontracting with Contractors Debarred, Suspended, or Proposed for Debarment and FAR 52.209-7 Information Regarding Responsibility
Matters.
a)
b)
c)
d)
e)
Is the Company currently debarred by the U.S. Government? Yes
No
Has the Company been convicted or had a civil judgment against them for fraud or commission of a criminal offense in obtaining a Federal, State, Local contract or
subcontract in the last 3 years? Yes
No
Is this Company currently indicted or otherwise charged by a government entity for any offense as stated in question 2? Yes
No
Has the Company been notified of any delinquent Federal taxes that exceed $3,000 in the last 3 years for which the liability remains unsatisfied? Yes
No
Has the Company had one or more contracts terminated for default by any Federal agency the last 3 years? Yes
No
MARINE & LAND SYSTEMS
Page 3 of 3
TMLS 5-2599A (12/2014)
REPORTING EXECUTIVE COMPENSATION AND FIRST TIER SUBCONTRACT AWARDS ( FAR 52.204-10)
In the preceding fiscal year:
a) Was your company’s gross income, from all sources over $3,000? Yes
If your response was “No”, please skip to next section:
b)
c)
d)
No
Did your company receive 80% or more of your annual gross revenues from Federal contracts (and subcontracts), loans, grants (and subgrants) and cooperative
agreements? Yes
No
Did your company receive $25,000,000 or more in annual gross revenues from Federal contracts (and subcontracts), loans, grants (and subgrants) and cooperative
agreements? Yes
No
Does the public have access to information about your company’s top executives through periodic reports filed under section 13(a) or 15(d) of the Securities
Exchange Act of 1934 (15 U.S.C. 78m(a), 78o(d) or section 6104 of the Internal Revenue Code of 1986? Yes
No
If you answered “Yes” to b) and c) and “No” to d), then please provide the name and total compensation for each of the five (5) most highly compensated executives for your
company for the preceding completed fiscal year in the space provided below.
Name (please print)
Compensation Amount
1)
2)
3)
4)
5)
REQUIREMENTS FOR CONTRACTS INVOLVING EXPORT-CONTROLLED ITEMS
ITAR Notification:
This note serves as official notification that (1) certain information, software, and hardware items received by your company from Textron Systems Marine & Land Systems
constitute “Defense Articles” as defined in and governed by the International Traffic in Arms (“ITAR”), and (2) any transfer of such Defense Articles by any means to a
“Foreign Person” as defined by the ITAR or placement of ITAR-controlled Technical Data in the public domain, whether in the U.S. or abroad, without prior approval from
the U.S. Department of State Directorate of Defense Trade Controls (“DDTC”) is prohibited by law.
Registration with Directorate of Defense Trade Controls (DDTC) as Manufacturer or Exporter of Defense Articles (22 CFR Part 122):
NOTICE: All manufacturers, exporters, and brokers of defense articles, defense services, or related technical data, as defined on the United States Munitions List (Part 121
of the International Traffic in Arms Regulations (ITAR)), are required to register with the U.S. Department of State Directorate of Defense Trade Controls (DDTC). Textron
Systems Marine & Land Systems is a manufacturer of defense articles, and as such, its suppliers of specifically designed parts, components, accessories and attachments are
also considered manufacturers of defense articles under the ITAR. Therefore, in order to comply with the ITAR, Textron Systems Marine & Land Systems’ U.S. suppliers of
defense articles under subcontract to Textron Systems Marine & Land Systems must access: http://www.pmddtc.state.gov/registration/index.html and review the DDTC
Registration Requirements.
Is your company registered with DDTC? Yes
Signature
Title (Print)
No
Commercial product N/A
Name (Print)
Date
Note: Form shall be valid for no more than one year from date signed. Firms are required to advise Textron of any change in status to any of the annotations listed above.
Textron Systems reserves the right to request an updated form at its discretion.
MARINE & LAND SYSTEMS