Std 843 Form PDF Details

The State of California’s Department of General Services Procurement Division has long recognized the contributions of disabled veteran business owners by instituting a formal process to support their enterprises. The STD 843 form, known as the Disabled Veteran Business Enterprise (DVBE) Declarations, serves as a pivotal piece of documentation within this framework. Updated last in May 2006, this form underscores the commitment required from disabled veteran owners and managers who aim to engage in providing materials, supplies, services, or equipment to the state. Its provisions are specifically designed to ensure that these enterprises are not merely acting as brokers or agents unless explicitly declared and accounted for, in alignment with the Military and Veterans Code Section 999.2. Signatories of the form are reminded of the severe consequences of misdemeanors, potential imprisonment, or fines alongside civil penalties for violations, underscoring the state’s seriousness in ensuring compliance and integrity in its engagements with DVBEs. Furthermore, the form details requirements for DVBEs that rent equipment, emphasizing the necessity of majority ownership and continuous certification in accordance with the military and veterans’ regulations. This rigorous documentation process, secured under the penalty of perjury, aims not only to facilitate the state’s goal of achieving a 3-percent DVBE participation but also to uphold the economic integrity and support towards disabled veterans' contributions to the state’s fabric.

QuestionAnswer
Form NameStd 843 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names3-percent, std 843 rev 5 2006, 2006, std 843 form

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STATE OF CALIFORNIA – DEPARTMENT OF GENERAL SERVICES PROCUREMENT DIVISION

DISABLED VETERAN BUSINESS ENTERPRISE DECLARATIONS

STD. 843 (Rev. 5/2006)

Instructions: The disabled veteran (DV) owner(s) and DV manager(s) of the Disabled Veteran Business Enterprise (DVBE) must complete this declaration when a DVBE contractor or subcontractor will provide materials, supplies, services or equipment [Military and Veterans Code Section 999.2]. Violations are misdemeanors and punishable by imprisonment or fine and violators are liable for civil penalties. All signatures are made under penalty of perjury.

 

 

SECTION 1

 

 

 

 

 

Name of certified DVBE:

 

 

DVBE Ref. Number:

 

 

Description (materials/supplies/services/equipment proposed):

 

 

 

 

 

Solicitation/Contract Number:

SCPRS Ref. Number:__________________________

 

 

 

 

 

(FOR STATE USE ONLY)

 

 

SECTION 2

 

 

 

 

 

APPLIES TO ALL DVBEs. Check only one box in Section 2 and provide original signatures.

I (we) declare that the DVBE is not a broker or agent, as defined in Military and Veterans Code Section 999.2 (b), of materials, supplies, services or equipment listed above. Also, complete Section 3 below if renting equipment.

Pursuant to Military and Veterans Code Section 999.2 (f), I (we) declare that the DVBE is a broker or agent for the principal(s) listed below or on an attached sheet(s). (Pursuant to Military and Veterans Code 999.2 (e), State funds expended for equipment rented from equipment brokers pursuant to contracts awarded under this section shall not be credited toward the 3-percent DVBE participation goal.)

All DV owners and managers of the DVBE (attach additional pages with sufficient signature blocks for each person to sign):

(Printed Name of DV Owner/Manager)

 

(Signature of DV Owner/ Manager)

 

(Date Signed)

 

 

 

 

 

(Printed Name of DV Owner/Manager)

 

(Signature of DV Owner/Manager)

 

(Date Signed)

Firm/Principal for whom the DVBE is acting as a broker or agent:

(If more than one firm, list on extra sheets.)

 

(Print or Type Name)

Firm/Principal Phone:

 

Address:

 

SECTION 3

APPLIES TO ALL DVBEs THAT RENT EQUIPMENT AND DECLARE THE DVBE IS NOT A BROKER.

Pursuant to Military and Veterans Code Section 999.2 (c), (d) and (g), I am (we are) the DV(s) with at least 51% ownership of the DVBE, or a DV manager(s) of the DVBE. The DVBE maintains certification requirements in accordance with Military and Veterans Code Section 999 et. seq.

The undersigned owner(s) own(s) at least 51% of the quantity and value of each piece of equipment that will be rented for use in the contract identified above. I (we), the DV owners of the equipment, have submitted to the administering agency my (our) personal federal tax return(s) at time of certification and annually thereafter as defined in Military and Veterans Code 999.2, subsections (c) and (g). Failure by the disabled veteran equipment owner(s) to submit their personal federal tax return(s) to the administering agency as defined in Military and Veterans Code 999.2, subsections

(c) and (g), will result in the DVBE being deemed an equipment broker.

Disabled Veteran Owner(s) of the DVBE (attach additional pages with signature blocks for each person to sign):

(Printed Name)

 

 

 

(Signature)

 

 

(Date Signed)

 

 

 

 

 

 

 

(Address of Owner)

 

 

 

(Telephone)

(Tax Identification Number of Owner)

Disabled Veteran Manager(s) of the DVBE (attach additional pages with sufficient signature blocks for each person to sign):

(Printed Name of DV Manager)

 

(Signature of DV Manager)

 

(Date Signed)

Page of

PRINT CLEAR

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1. It's very important to complete the dvbe form 843 correctly, therefore pay close attention while filling in the segments that contain all these blank fields:

Writing section 1 of 3-percent

2. The third step would be to fill out these particular blanks: Printed Name of DV OwnerManager, Signature of DV OwnerManager, Date Signed, FirmPrincipal for whom the DVBE is, g as a broker or age, If more than one firm list on, Print or Type Name, FirmPrincipal Phone, Address, APPLIES TO ALL DVBEs THAT RENT, SECTION, Pursuant to Military and Veterans, The undersigned owners owns at, Failure by the disabled veteran, and Disabled Veteran Owners of the.

3-percent completion process shown (portion 2)

You can potentially make an error while completing your APPLIES TO ALL DVBEs THAT RENT, so be sure you reread it prior to when you submit it.

3. In this step, review Printed Name of DV Manager, Signature of DV Manager, Date Signed, Page, PRINT, and CLEAR. All of these must be filled out with utmost attention to detail.

PRINT, Printed Name of DV Manager, and Date Signed in 3-percent

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