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Puerto Rico No-Change Affidavit Form

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Puerto Rico No-Change Affidavit Form
Puerto Rico No-Change Affidavit Form
NO-CHANGE AFFIDAVIT
I hereby affirm that the foregoing statements are true and correct and include all material
information necessary to identify and explain the operation of
________________________________________________________________________________
Name of Firm
The information requested is solely to determine if the firm qualifies as a small business: The Gross
receipts of the company for each of the last three (3) years: Please include the personal net worth and
corporate financial statements of the firm for the last year as attachments.
1. Year ending
$
2. Year ending
$
3. Year ending
$
The undersigned agrees to provide through the Prime Contractor or directly to the Grantee, current,
complete and accurate information in relation to the certification of the Firm as a D/WBE firm with the
Unified Certifications Program of the Commonwealth of Puerto Rico; and affirms that there have been
no changes in the circumstances affecting its ability to meet the size, disadvantaged status, ownership,
or control requirements of 49 CFR Part 26. There have been no material changes in the information
provided with
application for certification,
Name of the Company
except for any changes about which you have provided written notice to the UCP under 26.83 (I). The
above mentioned firm meets Small Business Administration (SBA) criteria for being a small business
concern and its average annual gross receipts (as defined by SBA rules) over the firm’s previous three
fiscal years do not exceed $22.41 million.
_____________________ Authorized Signature
Date
_____________________________
AFFIDAVIT NO.: ___________________
Name (Print)
SWORN and subscribed before me by ______________________________________, of legal age,
Name
__________________________________, __________________________________, Resident
of
marital status
occupation
__________________, SSC# _____________, known to me personally or whom I have identified by
means of __________________________________. In _________ Puerto Rico this ______ day of
Indicate Id. # of / government issued Id.
__________________, 20 ____.
Notary Public
Puerto Rico No-Change Affidavit Form