Fillable Printable Sbir Application Vcoc Certification

Sbir Application Vcoc Certification

OMB No. 0925-0001 (Rev. 06/15 Approved Through 03/31/2020) Page 1 SBIR Application VCOC Certification

NIH & CDC Small Business Innovation Research Program

Certification for Applicants That Are Majority-Owned by Multiple Venture Capital Operating

Companies, Hedge Fund, or Private Equity Firms

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for

reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the

collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of

information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other

aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705

Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0001). Do not return the completed form to this

address.

Any small businesses that are majority-owned by multiple venture operating companies (VCOCs), hedge funds

or private equity firms and are submitting an application for an SBIR funding agreement must complete this

certification prior to submitting an application. This includes checking all of the boxes and having an authorized

officer of the applicant organization sign and date the certification each time it is requested.

Please read carefully the following certification statements. The Federal government relies on the information to

determine whether the business is eligible for a Small Business Innovation Research (SBIR) Program award and

meets the specific program requirements during the life of the funding agreement. The definitions for the terms

used in this certification are set forth in the Small Business Act, SBA regulations (13 C.F.R. Part 121), the SBIR

Policy Directive and also any statutory and regulatory provisions referenced in those authorities.

If the funding agreement officer believes that the business may not meet certain eligibility requirements at the

time of award, they are required to file a size protest with the U.S. Small Business Administration (SBA), who

will determine eligibility. At that time, SBA will request further clarification and supporting documentation in

order to assist in the verification of any of the information provided as part of a protest. If the funding

agreement officer believes, after award, that the business is not meeting certain funding agreement

requirements, the agency may request further clarification and supporting documentation in order to assist in the

verification of any of the information provided.

Even if correct information has been included in other materials submitted to the Federal government, any

action taken with respect to this certification does not affect the Government’s right to pursue criminal, civil or

administrative remedies for incorrect or incomplete information given in the certification. Each person signing

this certification may be prosecuted if they have provided false information.

The undersigned has reviewed, verified and certifies that (all boxes must be checked):

1. The applicant is NOT more than 50% owned by a single VCOC, hedge fund or private equity firm.

Yes No

2. The applicant is more than 50% owned by multiple domestic business concerns that are VCOCs,

hedge funds, or private equity firms.

Yes No

3. I have registered with SBA at www.SBIR.gov as a business that is majority-owned by multiple

VCOCs, hedge funds or private equity firms.

Yes No

OMB No. 0925-0001 (Rev. 06/15 Approved Through 03/31/2020) Page 2 SBIR Application VCOC Certification

I understand that the information submitted may be given to Federal, State and local agencies for

determining violations of law and other purposes.

All the statements and information provided in this form and any documents submitted are true, accurate

and complete. If assistance was obtained in completing this form and the supporting documentation, I have

personally reviewed the information and it is true and accurate. I understand that, in general, these statements

are made for the purpose of determining eligibility for an SBIR funding agreement and continuing eligibility.

I understand that the certifications in this document are continuing in nature. Each SBIR funding

agreement for which the small business submits an offer or application or receives an award constitutes a

restatement and reaffirmation of these certifications.

I understand that I may not misrepresent status as small business to: 1) obtain a contract under the Small

Business Act; or 2) obtain any benefit under a provision of Federal law that references the SBIR Program.

I am an officer of the business concern authorized to represent it and sign this certification on its behalf.

By signing this certification, I am representing on my own behalf, and on behalf of the SBIR applicant or

awardee, that the information provided in this certification, the application, and all other information submitted

in connection with this application, is true and correct as of the date of submission. I acknowledge that any

intentional or negligent misrepresentation of the information contained in this certification may result in

criminal, civil or administrative sanctions, including but not limited to:

(1) fines, restitution and/or imprisonment under 18 U.S.C. §1001;

(2) treble damages and civil penalties under the False Claims Act (31 U.S.C. §3729 et seq.);

(3) double damages and civil penalties under the Program Fraud Civil Remedies Act (31 U.S.C. §3801 et

seq.);

(4) civil recovery of award funds,

(5) suspension and/or debarment from all Federal procurement and nonprocurement transactions (FAR

Subpart 9.4 or 2 C.F.R. part 180); and

(6) other administrative penalties including termination of SBIR/STTR awards.

OMB No. 0925-0001 (Rev. 06/15 Approved Through 03/31/2020) Page 3 SBIR Application VCOC Certification

My signature is verification that the statements checked () above are true and complete. I am aware that any

false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties.

Date

Signature

Printed Name (First, Middle, Last)

Title

Organization Name