Form 355 Information for Small Business Size Determination

OMB Approval No: 3245-0101 Expiration Date: 7/31/2025

INFORMATION FOR SMALL BUSINESS SIZE DETERMINATION

General Instructions

CAREFULLY READ ALL OF THESE INSTRUCTIONS AND THE SBA SIZE REGULATIONS BEFORE COMPLETING THIS FORM.

Providing the information is required in order for you to obtain a size determination from SBA. Failure to submit the information or submitting incomplete information may affect the size determination.

1. The information provided in this form will be used by the Small Business Administration (SBA) for a size determination of a business applying for assistance available to small businesses under any program administered by this Agency, except for its Small Business Investment Companies (SBIC) Program, which uses SBA Form 480, or at the request of another Federal agency for purposes of its small business program. A small business is a concern which is independently owned and operated, not dominant in its field of operation, and does not exceed the size standard applicable to the procurement or program for which the business is seeking participation. SBA defines a concern to be a business entity organized for profit, with a place of business located in the United States, and which operates primarily within the United States or which makes a significant contribution to the U.S. economy through payment of taxes or use of American products, materials or labor. 13 CFR § 121.105.

2. SBA is authorized to make size determinations pursuant to the Small Business Act, 15 USC 637(a), and regulations thereunder for the purpose of deciding small business protests and to determine eligibility for program assistance. SBA's size regulations are found generally at Title 13 of the Code of Federal Regulations, Part 121. SBA may, at its discretion, request additional information not specifically identified on this form.

3. The applicant must return one copy of SBA Form 355, with additional sheets attached as needed, to the same SBA Office of Government Contracting that provided the form. The person signing this form must be authorized to do so. Non-employee representatives of the business, such as an attorney or accountant, must provide a letter authorizing them to represent the business. The information provided must be complete. Failure to supply complete information may cause delays in making a size determination or lead to an adverse inference that the business is other than small.

4. All affiliates of the applicant business, whether acknowledged or not, and whether foreign or domestic, must be disclosed. SBA's criteria for defining affiliates should be carefully reviewed. In 13 CFR § 121.103, SBA identifies various forms of affiliation. You can find this regulation on the size standards website at

http://www.sba.gov/size. Separate affiliation rules apply to the SBA Business Loan, Disaster Loan, and Surety Bond Guarantee programs (13 CFR § 121.301) and to SBIR and STTR programs (13 CFR § 121.702). The website also provides some examples of affiliation in the “affiliation discussion” document. Dormant or inactive firms must be disclosed unless legally dissolved. Completion of Part V of this form does not constitute an admission or confirmation of affiliation.

5. Where the applicable size standard involves numbers of employees, SBA examines the applicant business's average number of employees on payroll for the 24 completed calendar months preceding the date of application or offer, including all employees who are hired on a full-time, part-time, temporary or other basis, including employees of domestic and foreign affiliates. See 13 CFR § 121.106 of SBA's regulations. For purposes of Economic Injury Disaster Loans, SBA examines the average number of employees for the 24 months preceding the disaster.

6. Where applicable size standards involve “average annual receipts,” the applicant business's annual receipts means total income (or gross income in the case of a sole proprietorship) plus cost of goods sold, as these terms are defined and reported on the business's Federal income tax return. For certifications on or before January 6, 2022, the applicant may choose to use a 3-year average or a 5-year average. After January 6, 2022, the applicant must use a 5-year average. An applicant in the Business Loan, Disaster Loan, or Surety Bond Programs may choose to use a 3-year average or a 5-year average. Applicants with fewer than five years in business should consult the regulation. See 13 CFR § 121.104 of SBA's regulations.

SBA FORM 355 07-22 previous editions are obsolete

7. For certain assistance programs, SBA must determine the primary industry activity or the North American Industry Classification System (NAICS) code of a business as part of its size determination. For this, SBA considers the distribution of receipts, employees and costs of doing business among the different industries in which business operations occurred for the most recently completed fiscal year. SBA may also consider other factors, such as the distribution of patents, contract awards, and assets. See 13 CFR § 121.107.

8. For purposes of this form, consider principal stockholders as those persons or concerns which own 10 or more percent of the voting stock. In cases where no individual or concern owns at least 10 percent of the voting stock, the five largest stockholders and their percentages of stock must be listed.

9. Where certain financial assistance programs are involved, the business must state whether government funds (loans or grants) to be received will be used in a Labor Surplus Area. Labor Surplus Areas are defined in the Department of Labor publications "Area Trends in Employment and Unemployment." See 13 CFR § 121.301(e).

10. Certain industries require special information. Please review the Size Standards Table and any applicable footnote in 13 CFR § 121.201.

CRIMINAL PENALTIES FOR FALSE STATEMENTS:

Any intentional or negligent misrepresentation of the information contained in this form, or other documents submitted for purposes of the size determination, may result in criminal, civil or administrative sanctions including, but not limited to: 1) fines of up to $500,000, and imprisonment of up to 10 years, or both, as set forth in 15 U.S.C. § 645 and 18 U.S.C. § 1001, as well as any other applicable criminal laws; 2) treble damages and civil penalties under the False Claims Act; 3) double damages and civil penalties under the Program Fraud Civil Remedies Act; and 4) suspension and/or debarment from all Federal procurement and non-procurement transactions.

CERTIFICATION:

I hereby certify that (1) I have made diligent efforts to obtain all information needed to complete this form; (2) I have reviewed all of the responses to the questions in this form, all exhibits and attachments submitted with this form, and all other documents and information that may be submitted subsequently; and (3) all information, exhibits, attachments, documents, and information that I submitted, or may be submitted subsequently, are true and correct to the best of my knowledge. I understand that the U.S. Small Business Administration (SBA) is relying on this information in order to make a size determination so that my business may receive assistance under the laws and regulations administered by SBA or so that my business can obtain a Federal contract.

(name of sole proprietorship, partnership, limited liability company or corporation)

By: Signature

Name and Title:

Date of signing:

PLEASE NOTE: The estimated burden hours for the completion of this form is 4 hours. You are not required to respond to this information collection if a valid OMB approval number is not displayed. If you have any questions or comment concerning this estimate or any other aspect of this information collection, please contact the U.S. Small Business Administration, Director, Records management Division, 409 3^rd Street, S.W., Washington, DC 20416 and/or SBA Desk Officer, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, DC 20503. PLEASE DO NOT SEND FORMS TO OMB.

SBA FORM 355 07-22 previous editions are obsolete

OMB Approval No: 3245-0101 Expiration Date: 7/31/2025

INFORMATION FOR SMALL BUSINESS SIZE DETERMINATION

Part I. Information relating to applicant business only:

1a. Name and address of applicant business 1b. Name and title of person authorized to provide (Street, City, State & Zip Code) information:

Telephone No.:

Fax No.:

E-mail address:

Unique Entity ID of applicant:

1c.

If determination is needed for a financial assistance program other than surety bond guarantee, will assistance funds be used in a labor surplus area?

yes no

If yes, identify labor surplus area:

1d. Date applicant was established or incorporated:

□

□

□

Select type of business entity and provide as an attachment the corresponding information for the business entity chosen:

□

Partnership

Corporation

LLC

Other (including joint ventures)

Attach a copy of partnership agreement.

Attach articles of incorporation and a copy of latest annual report to stockholders, if any, and bylaws.

Attach a copy of its articles of organization and operating agreement.

Identify business legal form and attach appropriate documents verifying ownership and structure.

1e. Primary business activity by North American Industry Classification System (NAICS) code

1f. Is applicant business organized for profit? Yes No

If business is not organized for profit, stop and check with the SBA Government Contracting Office about whether to continue.

2. Has applicant previously been the subject of a formal SBA size determination? Yes No If yes, then Case Number

Date

2. Does applicant operate under a franchise or license from another concern? yes no

If yes, attach a copy of agreement.

2. Name and address of all owners, partners, principal stockholders, or members of business organization.

If the applicant is owned by one or more entities (i.e., not individuals), provide the names of all owners of the entities and their percentage of ownership. This information must be provided for owners of all entities until the applicant identifies the ultimate owners who are natural persons. Attach additional sheets if necessary.

Name	% of ownership interest in the applicant

2. Name of all officers of applicant. Attach additional sheets if necessary.

Name	Position held

2. Name the members of the Board of Directors, if a corporation. If an LLC, name the Manager(s) or members of the Board of Managers, and, if an LP, name the General Partner(s). Attach additional sheets if necessary.

Name	Position held

7a. Has the applicant issued any stock options (or is the issue of any pending)? yes no.

If yes, identify person or concern holding options and amount.

7b. Has the applicant pledged any stock as collateral? yes no.

If yes, provide details of arrangement.

7c. Is any of the applicant’s stock held by a trust, voting trust, or voted in accordance with a shareholder’s agreement?

yes no.

If yes, provide relevant documents.

8. Are there any pending or recently completed mergers, or sale of the applicant by stock or assets? yes no. If yes, submit details and copies of relevant documents.

9a. Is the applicant or any person listed in questions 4, 5, or 6 (i.e., the owner, partner, director, officer, member, employee, or principal stockholder) an owner, officer, director, manager or employee of another business? yes no.

If yes, complete section 9b below.

9b. Attach additional sheets if necessary.

Name of person/business	Names of other businesses and addresses	Position held in other business	% of ownership interest in other business.

Part II. Information relating to employee-based size standards. Only complete if applicant is being evaluated under an employee- based size standard.

10. Provide the average number of employees of the applicant based upon numbers of employees (full-time, part-time, temporary, or employed on other basis) for each of the pay periods for the 24 completed calendar months preceding the date that size is being determined.

Part III. Information relating to receipts-based size standards. Only complete if applicant is being evaluated under a receipts-based size standard.

10. What is the ending date of the applicant’s fiscal year?

10. (a)

For certifications made prior to January 6, 2022 or for loan or surety applicants, select whether the applicant elects to use a 3- year or a 5-year averaging period for average annual receipts:

3-year average 5-year average

(b) Annual receipts/gross income of the applicant for each of its most recently completed five fiscal years as of the date that size is being determined. If selecting a 3-year average in (a), only provide the most recently completed three fiscal years.

Year:	$
Year:	$
Year:	$
Year:	$
Year:	$
Total:	$

Part IV: Information about acknowledged affiliates.

10. Affiliates (domestic and foreign)

General Instruction #4 above provides guidance on determining whether a company is considered an “affiliate” of the applicant and whether information about the affiliate must be reported. Include as an affiliate any businesses that the applicant’s owner(s) include on a Schedule C or Schedule E of their personal tax returns in which the owner or immediate family member has a controlling interest.

Note: All documentary materials about affiliates, including recorded documents, operating documents, financial and tax information are to be submitted with this form.

13a. Acknowledged affiliates. Attach additional sheets if necessary. If acknowledged affiliation is on a basis other than ownership, provide explanation of basis for affiliation.

Name and address of acknowledged affiliate	% of ownership interest that applicant has in this affiliate	% of ownership that this affiliate has in the applicant	NAICS code of primary product or service

13 b. Name of all owners, partners, directors, members, and principal stockholders of each business in 13a.

If any owners are entities (i.e., not individuals) provide names of the owners of the entities. This information must be provided for owners of all entities until the applicant identifies the ultimate owners who are natural persons. Attach additional sheets if necessary.

Name of individual	Affiliated business	Position held

13c. Number of employees currently employed by each business listed in 13a, if applicant is being evaluated under an employee- based size standard. (Attach separate sheet if needed)

13d. Annual receipts/gross income of each business listed in 13a for each of the most recently completed five fiscal years prior to the date size is being determined, if applicant is being evaluated under a receipts-based size standard . If selecting a 3-year average for certifications prior to January 6, 2022 or as a loan or surety applicant, only provide the most recently completed three fiscal years.

Attach additional sheets if necessary.

Year	Business 1:	Business 2:
	$:	$:
	$:	$:
	$:	$:
	$:	$:
	$:	$:
Total:	Total:	Total:

14a. Are there any persons listed in question 13b who are also owners, partners, directors, members or principal stockholders in another company? yes no. If yes, complete section 14b below.

14b. Attach additional sheets if necessary.

Name of person/business	Name of other businesses and addresses	Position held in other business	% of ownership interest held other business

Part V. Information about alleged or possible affiliates of applicant.

In cases where you are contesting alleged or possible affiliation, you must complete questions 15 – 21. The term “contesting” means the firm filling out this form does not agree with the allegations that it is affiliated with a firm noted in the size protest or request for size determination. If you are not contesting an alleged or possible affiliation, include the affiliate as an acknowledged affiliate in Part IV and complete questions 15 – 21 only if requested by SBA. For size protests relating to a specific procurement, questions 22 – 26 must be answered. Attach a separate explanation for any question answered “yes.”

15. Have any owners, officers, directors, key employees or managing members of the applicant ever been employed by or performed similar work for any alleged affiliates? yes no

15. Have any services been performed by the applicant for any alleged affiliates, or vice versa? yes no

15. As of the date that applicant’s size is being determined, did the applicant share or lease any facilities, equipment, or personnel with, from, or to any of the alleged affiliates (vehicles, telephone lines, office space, receptionist, etc.)?

yes no

15. Have there been or are there any current financial obligations between the applicant and the alleged affiliates?

yes no

15. Are there any individuals who have signed or are expected to sign documents to facilitate the ability of the applicant to receive bonding, indemnifications or credit guarantees, who are not owners, officers, directors, employees, partners, members or stockholders? yes no

15. Is any family member of an individual identified in the response to #4a principal stockholder, partner, or member of any of the alleged affiliates or another business? yes no

15. Has SBA ever determined the applicant to be affiliated with any of the alleged affiliates, or to the best of your knowledge, determined any of the alleged affiliates to be affiliated with each other?

yes no

If yes, attach a copy of the determination(s) if available, or describe the determination(s) made by SBA.

15. Will any of the alleged affiliates, or any of their principals, provide an indemnity or guaranty to a surety to facilitate a contract award to the applicant? yes no

Has such an indemnity or guaranty been provided within the past two years? yes no

15. Have any of the alleged affiliates assisted in arranging for any of the subcontractors needed for performance of this contract or any contract awarded to the applicant within the last two years? yes no

15. Have there been or are there any actual or proposed subcontracts between the applicant and any of the alleged affiliates?

yes no

15. Will any of the alleged affiliates perform as a subcontractor on this contract? yes no. Attach a copy of the agreement, if applicable.

15. In preparing the subject bid/proposal or request for assistance, was any assistance provided by an alleged affiliate?

yes no