State of California Department of General Services-Procurement…

State of California
Department of General Services-Procurement Division
AFFIDAVIT OF INCOME (7/1/2007)
Office of Small Business and DVBE Services (OSDS)
707 3rd Street, 1st Floor, Room 400
West Sacramento, CA 95605
(916) 375-4940  www.pd.dgs.ca.gov/smbus

The Affidavit of Income serves as a temporary proof of annual receipts submittal when the Federal Income Tax Return
for the most recently completed tax year has not yet been filed.
INSTRUCTIONS:
Small Business applicants must submit all of the following to the OSDS:
   · The completed sections A, B, and D of the Affidavit of Income.
   · A copy of an audited or unaudited Business Income Statement for the applicant and each of its affiliates (if any).
       The Income Statement must include:
            o The business name
            o The tax period/fiscal year being represented
            o The total revenue that is expected to be reported on the business' Federal income tax return as "Gross
                 Annual Receipts (less returns and allowances)" for the tax period/fiscal year being represented
   · If the business' tax filing due date has passed, include a copy of the tax filing extension for the applicant and
       each of its affiliates (if any)
DVBE applicants must submit to the OSDS:
   · The completed sections A, C, and D of the Affidavit of Income
   · If the business' tax filing due date has passed, include a copy of the tax filing extension for the applicant
ALL FIRMS:
Must replace their submitted Affidavit of Income with a hardcopy of the Federal tax return for the applicant (and each
affiliate if applying for small business certification) within the following timeframes (which ever occurs first):
      · Within 90 days of certification, or
      · Within two weeks of a tax filing extension's expiration (when a tax filing extension has been granted), or
      · When the tax return is filed with the Internal Revenue Service (IRS)
IMPORTANT! Failure to provide the Federal tax return(s) may result in the decertification of the applicant's Small Business and/or
Disabled Veteran Business Enterprise (DVBE) status.
A. BUSINESS NAME (ALL APPLICANTS)
APPLICANT'S NAME                                                                                              REF # (IF ALREADY CERTIFIED WITH THE OSDS)




B. SMALL BUSINESS APPLICANTS (ATTACH ADDITIONAL PAPER, IF NECESSARY)
FOR THE APPLICANT AND EACH AFFILIATE (IF ANY), ENTER THE GROSS ANNUAL RECEIPTS (LESS RETURNS AND ALLOWANCES) THAT IS EXPECTED TO BE REPORTED ON THE
BUSINESS' FEDERAL INCOME TAX RETURN FOR THE MOST RECENTLY COMPLETED TAX YEAR.

                                                             FROM TAX YEAR START        TO TAX YEAR END      GROSS ANNUAL RECEIPTS LESS RETURNS AND ALLOWANCES
                         BUSINESS NAME
                                                                 (MM/DD/YY)                (MM/DD/YY)         (AS REPORTED ON YOUR BUSINESS INCOME STATEMENT)

      APPLICANT
1                                                                                                            $


      AFFILIATE 1
2                                                                                                            $


      AFFILIATE 2
3                                                                                                            $


C. DVBE APPLICANTS
AS THE APPLICANT'S QUALIFYING DISABLED VETERAN, I ATTEST THAT THE OWNERSHIP INFORMATION TO BE REPORTED ON MY BUSINESS' INCOME TAX RETURN(S) FOR THE MOST
RECENTLY COMPLETED TAX YEAR WILL CONFIRM THAT THERE HAS BEEN NO CHANGE IN PERCENTAGE OF DISTRIBUTION OF PROFITS OR LOSSES AS DECLARED IN MY MOST RECENT
CERTIFICATION APPLICATION ON FILE WITH THE OFFICE OF SMALL BUSINESS AND DVBE SERVICES.

QUALIFYING DISABLED VETERAN'S SIGNATURE                              QUALIFYING DISABLED VETERAN'S PRINTED NAME                          DATE




D. REQUIRED SIGNATURE (ALL APPLICANTS)
ANY PERSON THAT WILLFULLY PROVIDES FALSE INFORMATION IS SUBJECT TO SERIOUS PENALTIES. THE SIGNATORY OF THIS DOCUMENT MUST BE THE APPLICANT FIRM'S OWNER (OR
OFFICER, IN THE CASE OF A CORPORATION) AND HEREBY CERTIFIES THAT HE/SHE HAS READ AND UNDERSTANDS THAT THE APPLICANT MEETS THE APPLICABLE SMALL BUSINESS AND/OR
DVBE CERTIFICATION REQUIREMENTS UNDER GOVERNMENT CODE SECTION 14835 ET SEQ., AND/OR MILITARY AND VETERANS CODE SECTION 999 ET SEQ., AND CALIFORNIA CODE OF
REGULATIONS, TITLE 2, SECTION 1896 ET SEQ., AND THAT THE FOREGOING STATEMENT AND ALL INFORMATION HEREIN IS TRUTHFUL AND ACCURATE. I DECLARE UNDER PENALTY OF
PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT.
OWNER'S OR CORPORATE OFFICER'S SIGNATURE                             OWNER'S OR CORPORATE OFFICER'S PRINTED NAME                         DATE