Form 3602 MDUFMA Small Business Qualification Certification

FormApproved: January9, 2004
ExpirationDate: December31. 2(X)6
OM B Statement: Seefollowing ~..

FY 2007 MDUFMA Small Business
Qualification Certification
Section

Informationabout Yourself
2. Federal Employer Identification Number:

1. Name of entity claiming MDUFMA Small Businessstatus:

3. Addresswhere entity is physicallylocated
---

4. Nameof personmakingthis Certification

DCheck (-'~me

6. Your mailing address

7. Your e-mail address

asitem 3

---

8. What is your relation to the entity claimingMDUFMA SmallBusinessstatus?
--

--

9. Haveyou listed all of the entity~saffiliates,partners,and parent firms on the secondpage(SectionII) of thiS
form?
Check (.I) oneresponse

DYes

0 The entity identified in item 1
hasno affiliates,partners,or parent firms

10. Complete,sign,and date the following certification

~

certify that
(

--

Nameci entity(mustbeidentical
to ~

to em I )

has
one
noresponse:)
affiliates,partners,or parentfinns,
asonly the affiliates,partners,andparentfinns listed on the back (SectionII) of this form,

and
(Checkoneresponse:)
Dreported "grossreceiptsor sales"of no more than $100,000,000on its most recent Federalincometax
return. I haveattacheda true and accuratecopy of the entity's most recent Federalincometax return.
rnogether with the affiliates,partners,andparentfirnis listed on the backof this form, reportedtotal "gross
receiptsor sales"of no morethan $100,000,000on their Federalincometax returns. I haveattachedatrue
and accuratecopy of the entity's most recent Federalincometax return, and a true and accuratecopy of
the most recent Federalincometax return of eachof the entity's affiliates, partners,and parentfirms.
I further certify that, to the best of my knowledge, the information I have provided in this Certification is complete
and accurate. I understand that submission of a false certification may subject me to criminal penalties under
18 V.S.C. § 1001 and other applicable federal statutes.

Signatureof personmakingthis Certification
Date of this Certification
Form FDA 3602 (For FY 2007) (6/2004)

OMB Control Number 0910-0508

SectionII - Informationabout Your Affiliates,Partners,and ParentFirms
c. Relationto Entity
Makingthis Certification
(Check
(J') an. ~nse)

a. Name of Entity

b. FederalEmployer
Identification
i Affiliate
Number (EIN)

d. Gross Receipts
or Salesfor
Most Recent
Tax Yetlr

Parent

Partnel

s
~

$

')

$

4

$

s
$
$
8

$

9

$

10

$
$

s
Ii
I~

Total Gross Receipts and Salesof All Affiliates, Partners, and Parent Firms (Sumof
lines1 - 12)

$
$0.00

Gross Receiptsand Salesof the E'ntityMakingthis Certification

$

Total Gross Receipts and Sales Used to Detennine Qualification as a MDUFMA
Small Business {Sumof lines13and14)

$
$0.00

Mail your completedFY 2007 MDUFMA Small BusinessQualification
Certification and copiesof your latest Federalincometax returns (including
the latestreturns of eachof your affiliate, partner,and parent firms) to FY 2007 MDUFMA Small Business Qualification (HFZ-222)
Division of Small Manufacturers, International, and Consumer Assistance
1350 Piccard Dr.
Rockville, MD 20850

(mAl Use Oriy)

~:

0 InfonTIation verified
0 Information not verified
(Decision ITUt be "Does not qualify")

~:

0 Qu.-r.es b- SmaI &S'IeSS fee (i$ccxJrn
OQuaifiesb-SmaII&S'IeSSfeeciscountsarM:
fee waiver for first premarket application

58007ODoesnot~
OMB Statement. The public reporting burden for this collection of infonnation is estimated to average 1 hour per response, including the time
for reviewing instructions, searchingexisting data sources,gathering and maintaining the data needed, and completing and reviewing the collection
of information. Send comments regarding this burden estimate or another aspect of this collection of information, including suggestionsfor
reducing this burden to:
Des-ltment of Health and Human Services
Food and Drug Administration
CBER, HFM-99
1401 Rockville Pike
Rockville, MD 20852-1448

and to

DeJ)8rtment of Health and Human Services
Food and Drug Administration
CDRH, HFZ-20
2098 Gaither Road
Rockvil1e,MD 20850

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currendy valid
Office of Mana2ement and Budget (OMB) control number.