Small Business Self Certification Statement PDF Details

When you are starting a small business, there are many things to take into consideration. One of the most important is making sure you comply with all the necessary legal requirements. The Small Business Self Certification Statement Form is one document you will need to complete and file with your state's Secretary of State office. This form lets the state know that your business is in compliance with all applicable laws. Here we will provide an overview of what is required on the form, and how to complete it accurately. Completing this form correctly is essential for keeping your small business in good standing with the government.

These are some details you might want to check out prior to starting dealing with the small business self certification statement.

Form NameSmall Business Self Certification Statement
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesform for self certification of business insurance, business certifications, sba small business self certification form, small business certification form

Form Preview Example

Small Business Self-Certiication Form


Company Name:









Phone Number:

Fax Number:


Cage Code:

Primary NAICS Code:


DUNS Number:

Number of Employees:


Business Size: (Please check all that apply)



Small Business

Certiied by SBA as Small Disadvantaged Business

Certiied by SBA as HUBZone Small Business

Women Owned Small Business

Veteran Owned Small Business

Service Disabled Veteran Owned Small Business


Minority Owned Small Business (Please specify Minority





Large Business

You may wish to review the deinitions for the above categories in the Federal Acquisition Regulation 19.7 or 52.219- 8 ( If you have dificulty ascertaining your size status, please call 1-800-U-ASK-SBA or refer to the SBA’s website at

Under 15 U.S.C. 645(d), any person who misrepresents company size status shall (1) be punished by a ine, 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.




This self-certiication is good for one year. It is your responsibility to notify us if your size or ownership status changes during that period. After one year, you are required to re-certify with us. Please e-mail this completed document to

2995 Sidco Drive, Nashville, Tennessee 37204 P: 615.383.1113 F: 615.386.8469

Watch Small Business Self Certification Statement Video Instruction

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