DGS PD 843 (Formerly STD. 843): DVBE Declarations

Enter the Name of certified DVBE and the DVBE Ref. Number.

Enter the Description (materials/supplies/services/equipment proposed).

Enter the Solicitation/Contract Number.

Section 2 applies to all DVBEs. Check only one box in Section 2.

Check the first box to 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 if renting equipment.

Check the second box to declare that the DVBE is a broker or agent for the principal(s) listed under Firm/Principal for whom the DVBE is acting as a broker or agent or on an attached sheet(s).

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) enter the Printed Name of DV Owner/Manager, the Signature of DV Owner/Manager and the Date Signed.

Enter the Firm/Principal for whom the DVBE is acting as a broker or agent (Print or Type Name), the Firm/Principal Phone and the Address. If more than one firm, list on extra sheets.

Section 3 applies to all DVBEs that rent equipment and declare the DVBE is not a broker.

Check this box if you 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.

Check this box when 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 and the DV owners of the equipment have submitted to the administering agency their personal federal tax return(s) at time of certification and annually thereafter.

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) enter the Printed Name, the Signature, the Date Signed, the Address of Owner, the Telephone and the Tax Identification Number of Owner.

Disabled Veteran Manager(s) of the DVBE (attach additional pages with sufficient signature blocks for each person to sign) enter the Printed Name of DV Manager, the Signature of DV Manager and the Date Signed.

Violations are misdemeanors and punishable by imprisonment or fine and violators are liable for civil penalties. All signatures are made under penalty of perjury.