8/2/2019 STEP GRANT SelfCertificationForm EligibilityCriteria DC

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DSLBD SELF CERTIFICATION FORM

TO THE APPLICANT: Please read this form carefully and completely before signing. The DC

Department of Small and Local Business Development shall not award STEP funding for

eligible expenses if the applicant does not meet the eligibility criteria of the DC STEP Program.You must complete and submit this certification form with your STEP Program Application.

I, ________________________, as________________________, certify that ______________________(name) (owner/partner/corporate officer) (business name)

trading as ___________________ at ______________________________________________________,(trade name) (business address)

using business tax number _________________________, as of this date, meets the basic DC eligibility(FEIN/SSN)

criteria required by the Department of Small and Local Business Development as follows (check all boxes

that apply):

Operates a business concern in the District of Columbia to manufacture, assemble, and/ordistribute an exportable product or provide an exportable service; Maintains principal office in the District of Columbia; Operates in the District of Columbia for at least six months prior to STEP Program approval; Licensed by the Department of Consumer and Regulatory Affairs (DCRA); and Registered with the Office of Tax and Revenue (OTR).

I understand that a signed and datedDSLBD Self Certification Form is required as documentation to

accompany my application for the DC STEP Program. I understand that completing and submitting this

form does not guarantee that my request for STEP funding will be approved.

I understand that the DC Department of Small and Local Business Development may conduct an

investigation to ascertain the veracity of the information contained in thisDSLBD Self Certification Form.

I understand that if I knowingly provide false information on thisDSLBD Self Certification Form, the DC

Department of Small and Local Business Development shall withhold STEP Program funding.

____________________________________________ _______________ ________________(Signature) (FEIN/SSN) (Date)

____________________________________________(Printed Name and Title)