ANNUAL SUPPLIER REPRESENTATIONS AND CERTIFICATIONS

Annual Supplier Representations and Certifications

Procurement of material, services and supplies for a United States Government contract requires that prime contractors, subcontractors and suppliers comply with socioeconomic programs enacted into public law, implemented by Executive Order, and promulgated by Federal Regulations. Representations and Certifications must be completed prior to award of any order(s) to your company and be updated annually.
- Company Name
- Company Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  
  Area CodePhone Number
- Fax Number
  
  Area CodePhone Number
- CAGE Code
- DUNS Number (FAR 52-204-6)
  NUMBERS ONLY - NO DASHES PLEASE
- Number of employees for last 12 months (FAR 52.212.3 (c)(8)(ii)(A))
  NUMBERS ONLY - NO DASHES PLEASE
- ****NAICS****
  NUMBERS ONLY - NO DASHES PLEASE. Seperate additional NAICS only with a comma. If you are certifying more than one NAICS code, you must ensure they are the same business size as certified in Section 2 of this form. If they are not, then you must request and complete a separate form for each business size.
- Please review each statement below and place a check mark in the box that represents your current state of compliance with each requirement. NOTE: DO NOT LEAVE ANY OF THE SECTIONS BLANK.
- TIN: Enter TIN number belowTIN has been applied forTIN is not offered because Offeror is a nonresident alien, foreign corporation, or foreign partnership that does not have income effectively connected with the conduct of a tradeor business in the United States and does not have an office or place of business or a fiscal paying agent in the United States;TIN is not offered because Offeror is an agency or instrumentality of a foreign governmentTIN is not offered because Offeror is an agency or instrumentality of the Federal Government
- Taxpayer Identification Number (TIN)
- Should be Empty:

Annual Supplier Representations and Certifications