HUBZone Certification (Historically Underutilized Business Zone)

Section A - Qualified HubZone
Principal Office Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Other Address (Mailing)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Is the Principal office location located in a qualified census tract?
- Yes
- No
Is the Principal office location located within the external boundary of a Federally recognized Indian reservation?
- Yes
- No
Is the Principal office location located within the BRAC Former Military Base?
- Yes
- No
Is the Principal office location located in a re-designated area?
- Yes
- No

Section D - Affiliation
Does the applicant concern own an interest in any other business?
- Yes
- No
Does any other business own an interest in the applicant concern?
- Yes
- No
Section E - Financial Information
Last fiscal year
MM slash DD slash YYYY
Last tax return filing date*
MM slash DD slash YYYY
Total Receipts ($)
Net profit ($)*
Current Assets ($)
Current Liabilities ($)*
Fixed Assets ($)*
Long-Term Liabilities ($)*
Other Assets ($)*
If for any reason, you are not able to supply the complete financial information, please explain why
Section F - HubZone Employment-Individual Employment Data
The applicant company has researched the resident status of its employees and has determined that at least 35% of all individuals employed on a full-time, part-time, or other basis, so long as that individual works a minimum of 40 hours per month, are HUBZone residents?*
- Yes
- No
The applicant company calculated the percentage of HUBZone residents utilizing current employment records as of the date of this application and will ensure that these records and all other pertinent information are maintained to document that at least 35% of all individuals employed on a full-time, part-time, or other basis, so long as that individual works a minimum of 40 hours per month, are HUBZone residents*
- Yes
- No
*
- As an officer, director, owner, legal representative or authorized representative of the organization stated throughout this document, I attest that all information provided is true and correct to the best of my knowledge.
Signature*
Title*
Date*
MM slash DD slash YYYY
Name of the organization*

Step 1 of 3

Section A - Qualified HubZone

Section B - General Information

Section D - Affiliation

Section E - Financial Information

Section F - HubZone Employment-Individual Employment Data