ACDBE/DBE ANNUAL NO CHANGE AFFIDAVIT

v20151207

TUCP

I, __________________________________________, swear

(or affirm) that there have been no changes in

Name of DBE firm owner(s)

_________________________________ circumstances affecting its ability to meet the size, disadvantaged

Name of DBE firm

status, ownership, or control requirements of 49 CFR Part 26 and 13 CFR Part 121. I swear (or affirm) there

have been no material changes in the information provided with _____________________________________

Name of DBE firm

(

Affidavit Form)

for certification, except for any changes about which I have provided written notice pursuant to

49 CFR § 26.83(i) to the City of Austin Small and Minority Business Resources Department.

I swear (or affirm) that I am socially disadvantaged because I have been subjected to racial or ethnic prejudice

or cultural bias, or have suffered the effects of discrimination, because of my identity as a member of one or

more of the groups identified in 49 CFR § 26.5, without regard to my individual qualities. I further swear (or

affirm) that my personal net worth does not exceed $1,320,000, and that I am economically disadvantaged

because 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 or similar line of business who are not socially and

economically disadvantaged.

I specifically swear (or affirm) ________________________________ continues to meet the Small Business

Name of DBE firm

Administration (SBA) business size criteria and the overall gross receipts cap of 49 CFR Part 26. I swear (or

affirm) that______________________________________ average annual gross receipts and/ or number of

Name of the DBE Firm

employees (as defined by SBA rules) over the previous three fiscal years does not exceed the SBA size

standards pursuant to 49 CFR Part §26.65 (a) (b) and 49 CFR Part §23.33. I provided the attached size and gross

receipts documentation to support this affidavit (captured and affirmed on page two).

Signature_______________________________________ Date _____________________________

On this_____ day of_____________, 20____, before me appeared (name)______________________________,

to me personally known, who, being duly sworn, did execute the foregoing affidavit and did state that he or she

was properly authorized by (name of firm) ________________________________________, to execute the

affidavit and did so as his or her free act and deed.

(SEAL/STAMP)

Notary Public _________________________________ Commission Expires___________________________

CONTINUED ON NEXT PAGE:

Knowingly and willfully providing false information to the Federal government is a violation of 18 U.S.C. Section 1001

(False Statements) and could subject you to fines, imprisonment or both.

ACDBE/DBE ANNUAL NO CHANGE AFFIDAVIT

v20151207

TUCP

Documentation to be included with this Affidavit Form:

• Previous year business returns for this firm and all affiliate firms.

Examples: Corporation-Form 1120, LLC or Partnership-Form 1065, Sole proprietorship-(entire) Form

1040 Schedule C

Firm’s current number of employees:

Employee Workplace Demographics

# of Local

Employees

# of Company-Wide

Employees

Total number of

Part

time

employees

Total number of

Full

time

employees

Total number of

Independently Contracted

Employees

Firm’s Exact Gross Receipts for the previous year: (Include these returns with your Affidavit

Form)

Year Ending Exact Gross Receipts

20____ $

Current Affiliate Firms: List all other firms that any owner holds ownership in or shares

resources with: (Include these returns with your Affidavit Form)

Affiliate Firm name

# of

employees

Gross receipts for

last tax year

Title with Affiliate

firm

Percentage of

ownership