Michigan Form 4106 – Fill Out and Use This PDF

This form is used to determine eligibility of non-Disadvantaged Business Enterprises (non-DBEs) to bid on Michigan Department of Transportation (MDOT) Small Business Program projects. This application must be submitted once a year, at least 30 days in advance of bidding.

Certified DBEs do not need to complete this form - annual verification of small business size is a requirement of certification.

Part 1. Information relating to applicant business only

NAME OF BUSINESS

ADDRESS OF BUSINESS		CITY		STATE	ZIP CODE
NAME AND TITLE OF AUTHORZIED SIGNER FOR THIS BUSINESS
TELEPHONE NO.	FAX NO.		E-MAIL ADDRESS
WHAT IS THE FEDERAL YEAR END TAX DATE FOR THE APPLICANT BUSINESS (Month/Date)
DESCRIBE THE MAJOR PRODUCTS OR SERVICES YOUR BUSINESS PROVIDES

1A. Business Major Products or Services – see FHVVJRYHRVZZZDLFV

	1C. Name of all officers			Address for each officer

	1D. Name of the Board of Directors of this
					Address of each member of the Board of Directors
	business, if a corporation

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1E. If any person listed in 1B, 1C, or 1D is an owner, partner, director, officer, member, employee or principal stockholder in

another business, please provide the following information (add extra pages if needed).

1F. Small Business Size Determination – Business Gross Receipts per tax form

Please complete this section if the NAICS codes identified is section 1A. base business size on gross receipts. The small business size table is available at http://www.sba.gov/sites/default/files/files/Size_Standards_Table.xls Under “Table of Size Standards.” You must provide copies of U.S. business tax forms showing gross receipts earned for the three consecutive fiscal years reported below for this business.

YEAR	DOLLARS
20	$
YEAR	DOLLARS
20	$
YEAR	DOLLARS
20	$
Total	$

1G. Total number of employees of the applicant business

Please complete this section if the NAICS codes identified in 1A determine business size using total number of employees. See http://www.sba.gov/sites/default/files/files/Size_Standards_Table.xls “Table of Size Standards.” You must provide copies of U.S. business tax forms showing total number of employees.

YEAR	20	TOTAL NUMBER OF ALL EMPLOYEES(Full-time, part-time, temporary, etc)
YEAR	20	TOTAL NUMBER OF ALL EMPLOYEES(Full-time, part-time, temporary, etc)
YEAR	20	TOTAL NUMBER OF ALL EMPLOYEES(Full-time, part-time, temporary, etc)
YEAR	20	TOTAL NUMBER OF ALL EMPLOYEES(Full-time, part-time, temporary, etc)

Part 2. Affiliates and Subsidiaries, including those identified in Part 1E.

13 CFR 121 – Stock ownership has to be 50% or more in another company – including when ownership is shared among several people.

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2A. Gross sales or receipts of 1st affiliate business for the past three fiscal years

You must provide copies of U.S. business tax forms for the fiscal years reported below which show gross receipts of all subsidiaries or affiliates.

YEAR	DOLLARS
20	$
YEAR	DOLLARS
20	$
Total	$

2B. Gross sales or receipts of 2nd affiliate business for the past three fiscal years

You must provide copies of U.S. business tax forms for the fiscal years reported below which show gross receipts of all subsidiaries or affiliates. If you have more than two affiliates or subsidiaries, please attach additional pages for those affiliates.

NAME AND ADDRESS OF 2nd AFFILIATE

YEAR	DOLLARS
20	$
YEAR	DOLLARS
20	$
YEAR	DOLLARS
20	$
Total	$
2C. Total number of employees of 1st affiliate

Please complete this section if the NAICS codes identified in section 1A. base business size on number of employees. The small business size table is available at http://www.sba.gov/sites/default/files/files/Size_Standards_Table.xls under “Table of Size Standards.” You must provide copies of U.S. business tax forms showing total numbers of full-time, part-time, temporary, or seasonal employees who have worked for this affiliate during each of the last three consecutive fiscal years.

YEAR	20	TOTAL NUMBER OF ALL EMPLOYEES(Full-time, part-time, temporary, etc)
YEAR	20	TOTAL NUMBER OF ALL EMPLOYEES(Full-time, part-time, temporary, etc)
YEAR	20	TOTAL NUMBER OF ALL EMPLOYEES(Full-time, part-time, temporary, etc)

2D. Total number of employees of 2nd affiliate

Please complete this section if the NAICS codes identified in section 1A. base business size on number of employees.

The small business size table is available at http://www.sba.gov/sites/default/files/files/Size_Standards_Table.xls under “Table of

Size Standards.” You must provide copies of U.S. business tax forms showing total numbers of full-time, part-time, temporary, or seasonal employees who have worked for this affiliate during each of the last three consecutive fiscal years. If you have more than two affiliates, attach separate pages containing the required information.

YEAR	20	TOTAL NUMBER OF ALL EMPLOYEES(Full-time, part-time, temporary, etc)
YEAR	20	TOTAL NUMBER OF ALL EMPLOYEES(Full-time, part-time, temporary, etc)
YEAR	20	TOTAL NUMBER OF ALL EMPLOYEES(Full-time, part-time, temporary, etc)

CERTIFICATION

I hereby certify that all information provided on this form and in attachments are true and correct to the best of my knowledge and belief. This information is submitted for the purpose of assisting the MDOT in making a size determination in order that my business may participate in the Race-Neutral Small Business Program.

NAME OF SOLE PROPRIETORSHIP, PARTNERSHIP, LIMITED LIABILITY COMPANY, OR CORPORATION

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Instructions FOR SMALL BUSINESS Program application

For participation in the Michigan Department of Transportation (MDOT)

SMALL BUSINESS PROGRAM

Carefully read these instructions and the United States Small Business Administration (SBA) size regulations found at 13 Code of Federal Regulations Part 121 before completing this form.

To qualify for the Small Business Program, applicants must meet SBA small business size standards for the industry in which the applicant will be bidding.

No business, including affiliates and subsidiaries, will qualify for this program if gross receipts as averaged over the previous three years exceed $22.41 million.

General Instructions

1.Information provided will be used by the MDOT to determine small business size of non- disadvantaged business enterprises (non-DBEs). MDOT may, at its discretion, request additional information not specifically identified on this form.

a.Non-DBEs must provide this information once a year, or at least 30 days before bidding, in order to bid on Small Business Program projects.

b.Michigan-certified DBEs do not need to complete this form. Annual verification of small business size is a condition of DBE certification.

2.Select North American Industry Classification System (NAICS) codes that best describe your business and then determine if the business meets size standards for the selected codes. SBA size standards are usually stated either in number of employees over the past 12 months, or average annual receipts over the past three years – whichever number represents the largest size of your business right now (including subsidiaries and affiliates). Size standards are available for every private sector industry in the U.S. economy, with the NAICS used to identify the industries. The steps are simple to determine your size:

a.Identify the NAICS code(s) that best describe(s) your business activities. http://www.census.gov/eos/www/naics/

See Identifying Industry Codes at http://www.sba.gov/content/identifying-industry- codes for more helpful resources.

b.Determine your Industry's size standard using the Table of Small Business Size Standards at http://www.sba.gov/content/table-small-business-size-standards. Match your NAICS code(s) with the appropriate size standard(s).

3.One copy of MDOT SBP Application, with additional sheets attached as needed, must be returned to the MDOT Office of Business Development.

4.The person signing this form must be authorized to do so. Non-employee representatives of the business, such as attorneys or accountants, must provide a letter authorizing them to represent the firm. The information requested must be complete. Failure to supply complete information may cause delays in making a size determination or impose adverse inferences that the business is not small.

5.All affiliates of the business, whether acknowledged or not, and whether foreign or domestic, must be disclosed. SBA's criteria for defining affiliates should be carefully reviewed. In 13 CFR §121.103, SBA identifies various forms of affiliation.

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(f)Affiliation based on identity of interest. Affiliation may arise among two or more persons with an identity of interest. Individuals or firms that have identical or substantially identical business or economic interests (such as family members, individuals or firms with common investments, or firms that are economically dependent through contractual or other relationships) may be treated as one party with such interests aggregated. Where SBA determines that such interests should be aggregated, an individual or firm may rebut that determination with evidence showing that the interests deemed to be one are in fact separate.

PENALTIES FOR CRIMINAL VIOLATIONS

It is a criminal offense to misrepresent in writing the status of a concern as a small business in order to obtain a prime or subcontract contract awarded pursuant to Section 9 or 15 of the Act (15 U.S.C. § 638 and § 644) and Section 8(a) of the Act ( 15 U.S.C. § 637(a)) or subcontract included as part or all of a goal contained in a subcontracting plan required according to the Section 8(d) of the Act (15 U.S.C. § 637 (d)), or prime or subcontract awarded under Federal Law that references Section 8(d) of the Act (15 U.S.C. § 637 (d)) that defines eligibility for such programs as the Small and Disadvantaged Business contracting program. Under Section 16(d) of the Act (15 U.S.C. 645(d)), the punishment for this offense is imprisonment of not more than 10 years or a fine of not more than $500,000 or both. It can also result in certain administrative penalties, such as suspension or debarment from further contracting with the US Government.

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PERSONAL FINANCIAL STATEMENT

As of		,

Complete this form for: (1) each proprietor, or (2) each limited partner who owns 20% or more interest and each general partner, or (3) each stockholder owning or (4) any person or entity providing a guaranty loan.

Name								Business Phone
Residence Address								Residence Phone
City, State, & Zip Code
Business Name of Applicant/Borrower
	ASSETS			(Omit Cents)				LIABILITIES			(Omit Cents)
Cash on hand & in Banks		$				Accounts Payable				$
Savings Accounts		$				Notes Payable to Banks and Others				$
IRA or Other Retirement Account		$				(Describe in Section 2)
Accounts & Notes Receivable		$				Installment Account (Auto)				$
Life Insurance-Cash Surrender Value Only		$				Mo. Payments	$
(Complete Section 8)		$				Installment Account (Other)				$
Stocks and Bonds						Mo. Payments	$
(Describe in Section 3)		$				Loan on Life Insurance				$
Real Estate						Mortgages on Real Estate				$
(Describe in Section 4)						(Describe in Section 4)
Automobile-Present Value		$				Unpaid Taxes				$
Other Personal Property		$				(Describe in Section 6)
(Describe in Section 5)						Other Liabilities				$
Other Assets		$				(Describe in Section 7)				$
(Describe in Section 5)						Total Liabilities
		$				Net Worth				$
	Total							Total		$
Section 1.	Source of Income					Contingent Liabilities
Salary		$				As Endorser or Co-Maker				$
Net Investment Income		$				Legal Claims & Judgments				$
Real Estate Income		$				Provision for Federal Income Tax				$
Other Income (Describe below)*		$				Other Special Debt				$

Description of Other Income in Section 1.

*Alimony or child support payments need not be disclosed in "Other Income" unless it is desired to have such payments counted toward total income.

Section 2. Notes Payable to Banks and Others. (Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.)

(tumble)

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Section 3. Stocks and Bonds. (Use attachments if necessary. Each attachment must be identified as a part of this statement and signed).

Section 4. Real Estate Owned.		(List each parcel separately. Use attachment if necessary. Each attachment must be identified as a part
		of this statement and signed.)
		Property A					Property B		Property C
Type of Property
Address
Date Purchased
Original Cost
Present Market Value
Name &
Address of Mortgage Holder
Mortgage Account Number
Mortgage Balance
Amount of Payment per Month/Year
Status of Mortgage
Section 5. Other Personal Property and Other Assets.				(Describe, and if any is pledged as security, state name and address of lien holder, amount of lien, terms
			of	payment and if delinquent, describe delinquency)

Section 6.

Unpaid Taxes.

(Describe in detail, as to type, to whom payable, when due, amount, and to what property, if any, a tax lien attaches.)

Section 7. Other Liabilities. (Describe in detail.)

Section 8.

Life Insurance Held.

(Give face amount and cash surrender value of policies - name of insurance company and beneficiaries)

I authorize SBA/Lender to make inquiries as necessary to verify the accuracy of the statements made and to determine my creditworthiness. I certify the above and the statements contained in the attachments are true and accurate as of the stated date(s). These statements are made for the purpose of either obtaining a loan or guaranteeing a loan. I understand FALSE statements may result in forfeiture of benefits and possible prosecution by the U.S. Attorney General (Reference 18 U.S.C. 1001).

Signature:	Date:	Social Security Number:
Signature:	Date:	Social Security Number:

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Small Business Program (SBP) Application Checklist and

required attachments:

Legal business name: ______________________________

PERSONAL NET WORTH (PNW)

All owners of businesses applying for the SBP must have a pnw less than $1.32 million. This figure excludes each owner’s primary residence, and the value of the business applying for participation in the SBP.

SMALL BUSINESS PROGAM SIZE

Businesses, including affiliates, qualifying for the SBP must not exceed the U.S. Small Business Administration size standard(s) for the North American Industry Classification (NAICS) code for the type(s) of work performed. In no case shall any eligible business, including affiliate businesses, have gross receipts over $22.41 million as averaged over the three most recent tax years.

The following documents must be provided in order for MDOT to determine eligibility to participate in the SBP:

฀A completed copy of the entire SBP application, signed and notarized with last 4 digits of SS #.

฀All assets listed as joint on PNW must provide a break down for each individual.

฀The personal financial statement must include the value of ownership in all other companies owned by the applicant.

฀United States 1040 Personal Income Tax Returns for the most recent three (3) consecutive years (i.e., 2009, 2010, 2011)

O Include all schedules and W-2’s.

฀Federal business tax returns for the most recent three (3) consecutive years for the applicant business and all affiliate businesses:

O Include all business tax schedules and required attachments and W-3’s.

฀Please DO NOT bind or staple the application

฀Mail completed application to the following address:

MDOT Office of Business Development,

P.O. Box 30050,

Lansing, Michigan 48909

Note: Incomplete application packages will be returned.