Minority Owned Business Certification

1 Texas Certification Agency, Inc., Austin, Texas, USA, (512) 852-4629 FAX, Minority Owned Business Certification Required Supporting Documentation for Texas Certification Directory Enrollment Texas Certification Agency, Inc., Austin, Texas, USA, (512) 852-4629 FAX, Texas Certification Agency, Inc., Austin, Texas, USA, (512) 852-4629 FAX, Supporting Documentation Required to Voluntarily-Participate in the Minority Owned Business Certification Program of Texas Certification Agency, Inc. Required Documentation: 1. A (1) valid and current copy of your United States of America or Foreign-Government issued Passport, or 2. 3. the United States of America Department of State issued Visa, or Driver's License issued from a state located within the United States of America. A (1) copy of the Business registration: Sole Proprietorship: Assumed Name (DBA) Filing from a Texas County Clerk. Corporations: Certificate of Existence / Fact from the Texas Secretary of State LLC: Certificate of Existence/ Fact from the Texas Secretary of State Limited Partnership: Certificate of Existence /Fact from the Texas Secretary of State Limiited Liability Partnerships: Certificate of Existence / Fact from the Texas Sec.

2 Of State General Partnership: Certificate of Existence / Fact from the Texas Secretary of State * Texas Secretary of State Corporations Division: (512) 463-5578 Online Document Retrieval and Cert. of Existence may be obtained at SOS Direct, * Texas Comptroller of Public Accounts: (800) 252-1381 Franchise Tax Account Status and Taxpayer Number may be obtained at The signed and notarized sworn affadavit provided by Texas Certification Agency, Inc., for each owner of Business entity that contributes to the 51% majority ownership structure. NOTE: "Socially Disadvantaged Groups" are defined by the Small Business Act as followed: Black Americans (African Descent). Hispanic Americans (persons with origins from Spanish or Portuguese speaking countries). Native Americans; (American Indians, Eskimos, Aleuts, or Native Hawaiians). Asian Pacific Americans (persons with origins from Burma, Thailand, Malaysia, Indonesia, Singapore, Brunei, Japan, China (including Hong Kong), Taiwan, Laos, Cambodia (Kampuchea), Vietnam, Korea, The Philippines, Trust Territory of the Pacific Islands (Republic of Palau), Republic of the Marshall Islands, Federated States of Micronesia, the Commonwealth of the Northern Mariana Islands, Guam, Samoa, Macao, Fiji, Tonga, Kiribati, Tuvalu, or Nauru).

3 Subcontinent Asian Americans (persons with origins from India, Pakistan, Bangladesh, Sri Lanka, Bhutan, the Maldives Islands or Nepal). All Faxed and / or Emailed Documentation Must Be 5MB and Under Per Submission Submit all documentation (ie. Points 1-3) to Texas Certification Agency, Inc., at: Fax: (512) 852-4629 or Email: Texas Certification Agency, Inc., Austin, Texas, USA, (512) 852-4629 FAX, (Sworn Affidavit Minority Owned Business Certification ) Page 1 of 2 Sworn Affidavit Minority Owned Business Certification A MATERIAL FALSE STATEMENT OR OMISSION MADE IN CONNECTION WITH THIS APPLICATION IS SUFFICIENT CAUSE FOR DENIAL OF VOLUNTARY PARTICIPATION IN THE TEXAS Certification AGENCY, INC. Minority Owned Business Certification PROGRAM, OR REVOCATION OF A PRIOR APPROVAL; AND MAY SUBJECT THE PERSON AND/OR ENTITY MAKING THE FALSE STATEMENT TO ANY AND ALL CIVIL AND CRIMINAL PENALTIES AVAILABLE PURSUANT TO APPLICABLE UNITED STATES OF AMERICA LAW AND STATE OF TEXAS LAW CONCERNING FALSE STATEMENT, FRAUD, OR OTHER APPLICABLE OFFENSES.

4 I, _____(printed full name), Swear under penalty of law that I am _____(title) of _____ (full legal company name including incorporation, limited liability, limited partnership, etcetera) with Texas Secretary of State Filing Number _____ or Texas County Clerk Filing Number _____ (sole proprietorships) Filed in the County of _____. (sole proprietorships) I maintain _____ (ownership percentage total) ownership within the firm and declare that I am a member of the "Socially Disadvantaged Group" of _____ (classified on the cover page) as defined by the Small Business Act. The aforementioned company's Texas Comptroller Number is _____. I acknowledge that I have read, agree, and understand the terms of service ( "Agreement" or "Contract")located at in connection with my application for voluntary participation in the Texas Certification Agency, Inc. Minority Owned Business Certification Program _____(initial) I acknowledge that this sworn affidavit is true and correct to the best of my knowledge, and that all responses to the questions in the Agreement electronically submitted in connection with this sworn affidavit are full and complete, omitting no material information.

5 The responses include all material information necessary to fully and accurately identify the firm/company, and verify its ownership and control. _____(initial) I recognize that the information submitted in this sworn affidavit is for the purpose of considering my application for voluntary participation into the Texas Certification Agency, Inc. Minority Owned Business Certification program. I understand that Texas Certification Agency, Inc. may, by means it deems appropriate, determine the accuracy, truth, and validity of statements and documents in this sworn affidavit and the electronically submitted Agreement filed in connection with my application for voluntary participation in the Texas Certification Agency, Inc. Minority Owned Business Certification program. I authorize Texas Certification Agency, Inc., to verify the information provided in all documentation related to this Application for purposes of determining the above-named entity's (initial) (Sworn Affidavit Minority Owned Business Certification ) Page 2 of 2 I agree to provide written notice to Texas Certification Agency, Inc.

6 , of any material change to the information contained within the electronically submitted Agreement or to this sworn affidavit within 5 Business days of such change ("material change" as defined in the Agreement/Contract). _____(initial) I acknowledge that all information submitted in the Agreement and this affidavit becomes Texas Certification Agency, Inc. property. I further acknowledge that Texas Certification Agency, Inc., is authorized to publicly display all information provided in the Agreement and this affidavit, as it relates to my voluntary participation in the Texas Certification Agency, Inc. Minority Owned Business Certification program, on the website _____(initial) I, the Applicant, hereby swear under penalty of the laws of the United States that the applicant is an owner of the aforementioned company. I, the undersigned applicant, agree to indemnify and hold Texas Certification Agency, Inc., its officers, directors, employees, agents, affiliates, partners, and volunteers ("Texas Certification Agency, Inc.)

7 , et al") harmless from any losses, claims, damages, liabilities, and related expenses (including the fees, charges, and disbursements in connection with any counsel or consultant retained by Texas Certification Agency, Inc., et al) incurred by or asserted against Texas Certification Agency, Inc., et al by the undersigned or any third party, arising out of, in connection with, or as a result of (i) the information submitted by applicant in the Agreement and this sworn affidavit, (ii) the processing of the Agreement and this sworn affidavit, (iii) the enrollment for or denial of voluntary participation in the Certification program; (iv) any actual or prospective claim, litigation, investigation, or proceeding relating to any of the foregoing and the prosecution and defense thereof; whether based on contract, tort, or any other theory, whether brought by a third party or the applicant, and regardless of whether Texas Certification Agency, Inc., et al are parties thereto; provided that this indemnity shall not be available to Texas Certification Agency, Inc.

8 , et al to the extent that such losses, claims, damages, liabilities or related expenses have resulted from the gross negligence, bad faith, or willful misconduct of Texas Certification Agency, Inc., et al. _____(initial) Applicant Name of Business :_____ (full legal name including the suffix: INC., LLC., LP., PLLC., etcetera) Signature of Owner/Date:_____ Notary On this _____ day of _____, 20_____, before me appeared (name)_____, who being duly sworn, did execute the following affidavit so as his or her free act deed. (Seal) Notary Public:_____ Commission expires: _____