Sba Form 1010A – Fill Out and Use This PDF

Applicant Business Name:

INSTRUCTIONS:

Answers to the following questions will be used to determine your personal eligibility for this program and all applicable questions should be fully addressed. When answers require additional space, use plain white paper properly identifying the item numbers.

I.SOCIAL DISADVANTAGE

1. I am a U.S. citizen.

Yes No

2. I am claiming social disadvantage because of my identification as a:

Black American

Hispanic American

Native American (American Indian, Eskimo, Aleut or Native Hawaiian)

Asian Pacific American (An individual with origins from Burma, Thailand, Malaysia, Indonesia, Singapore, Brunei, Japan, China, Taiwan, Laos, Cambodia (Kampuchea), Vietnam, Korea, The Philippines, U.S. Trust Territory of the Pacific Islands (Republic of Palau), Republic of the Marshall Islands, Federated States of Micronesia, The Commonwealth of the Northern Mariana Islands, Guam, Samoa, Macao, Hong Kong, Fiji, Tonga, Kiribati, Tuvalu, or Nauru.)

Subcontinent Asian American (An individual with origins from India, Pakistan, Bangladesh, Sri Lanka, Bhutan, the Maldives Islands or Nepal.)

Not applicable

If you have indicated your membership in one of the groups listed above, proceed to Section II, "Economic Disadvantage". If you have checked "Not Applicable", proceed to question 3 below and answer all applicable questions that follow. Refer to the Code of Federal Regulations, 13 C.F.R. 124.105(c), for 8(a) program regulations regarding the establishment of social disadvantage for individuals who are not members of the designated groups. Document fully any incidences of racial or ethnic prejudice or cultural bias or discriminatory practices which negatively impacted your entry into and/or advancement in the business world and over which you had no control. Please mark "N/A" under any questions not applicable to your circumstances. Answer all questions fully. You do not need to limit your responses to the space provided. Attach additional sheets as necessary.

SBA Form 1010A (7-96) Previous editions are obsolete

This form was electronically produced by Elite Federal

Forms, Inc.

3.I am claiming social disadvantage because of my membership in a group other than those listed above.

Yes

No

Identify basis for the claim of social disadvantage:

4. I am socially disadvantaged because I have personally been subjected to: (Check one or more)

Racial prejudice

Cultural bias

Ethnic prejudice

5.Are you a resident of a geographic area having long term chronic high unemployment and economic depression? If so, explain precisely how and whether such residence has caused and continues to cause cultural, social or economic disadvantage.

6.Do you have a chronic physical handicap which has led to discriminatory practices against you which have restricted and still restricts professional acceptance, employment, access to credit, capital and/or markets? If so, explain fully.

SBA Form 1010A (7-96) Previous editions are obsolete

Page 2

7.Have you because of your cultural, ethnic, or social background been subjected to chronic substantial discrimination which has caused you unemployment, limited educational opportunities or personal deprivation? If so, explain fully.

8.Have you experienced low income status because of apparent discriminatory practice? If so, explain precisely how such discriminatory practices led to your having limited access to needed technical, financial, or management resources and equal opportunity in obtaining contracts.

9.Use the space below to outline other specific and pertinent examples of chronic social and economic disadvantage not covered above.

SBA Form 1010A (7-96) Previous editions are obsolete

Page 3

II.ECONOMIC DISADVANTAGE

Because of racial and/or ethnic prejudice, and/or cultural bias, my ability to compete in the free enterprise system has been impaired due to diminished capital and credit opportunities as compared to others in the same business area who are not socially disadvantaged. (Same business area in this context means same line of business and same competitive market area.)

Yes No

If the answer is yes, document below how your ability to compete in the market place has been impaired by such things as inability to obtain adequate bonding, credit or financing; inability to obtain licenses, leases and certifications; restriction of your markets to certain racial, ethnic or social groups; unemployment, underemployment, etc. Be very specific when giving examples.

SBA Form 1010A (7-96) Previous editions are obsolete

Page 4

Read the following paragraphs carefully Your signature on this 8(a) Personal Eligibility Statement indicates your understanding and acceptance of these conditions:

a.Authority to Collect Personal Information: The Small Business Administration (SBA) is authorized to determine eligibility for the 8(a) Program under Section 124 of Title 13 of the U.S. Code of Federal Regulations. The information submitted on SBA Forms 1010A and 1010B is used to determine personal and business eligibility for the 8(a) Program. Information submitted may be given to Federal, State and local agencies for law violations.

b.Effects of nondisclosure: Omission of any information may be cause for this application not receiving timely and complete consideration.

c.Non-Authorized Representatives: There are no authorized representatives of SBA other than our regular salaried employees. Payment of any fee or gratuity to SBA employees is illegal and will subject the parties to such a transaction to prosecution.

d.Representatives and Fees: It is not necessary for you to retain representation to assist in the preparation and presentation of this or any other 8(a) application. However, if you do retain such representation, SBA will determine the reasonableness of fees or other compensation for services actually performed by representatives on your behalf.

e.True and Complete Statements: By signing this form you are certifying that all information in this 8(a) Personal Eligibility Statement, including exhibits, is true and complete to the best of your knowledge and is submitted for consideration of 8(a) Program eligibility.

f.False Statements: If you make a statement herein which you know to be false, under provisions of the Small Blusiness Act you can be subject to a fine of not more than $500,000 or by imprisonment for not more than 10 years, or both.

g.Use of Eligibility: Program regulations provide that neither a concern nor any individual whose personal disadvantaged status was required to qualify a concern for 8(a) program participation shall be eligible to reapply for program participation. You will be found to have used your eligibility for the 8(a) program if you claim disadvantaged status by completing this form and SBA approves the applicant concern for program participation.

Contact your local SBA office if you need assistance in preparing this or any other application material or if you have any questions concerning the payment of representatives fees.

Name of Business

Signature of Preparer if other than Applicant

Date

Printed or Typed Name of Preparer

Signature of the Applicant

Date

Printed or Typed Name and Title

PLEASE NOTE: The estimated burden hours for the completion of this form is 1 hour per respnse. You will not be required to respond to this information collection if a valid OMB approval number is not displayed. If you have questions or comments concerning this estimate or other aspects of this information collection, please contact the U.S. Small Business Administration, Chief, Administrative Information Branch, Washington, D.C. 20416 and/or Office of Management and Budget, Clearance Officer, Paperwork Reduction Project (3245-0015), Washington, D.C. 20503.

SBA Form 1010A (7-96) Previous editions are obsolete

Page 5