WORLDWIDE PROCUREMENT & LOGISTICS
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TEXAS INSTRUMENTS INCORPORATED * SUPPLIER INFORMATION MANAGEMENT P O BOX 650311 * M/S 3913 * DALLAS TX 75265-0311 * PHONE 972-917-4265 * FAX 972-917-4331 TI-28992J-web1 LARGE, SMALL, AND SMALL DISADVANTAGED BUSINESS DEFINITIONS AND CERTIFICATIONS A. LARGE BUSINESS CONCERN - A major corporation with more than 500 employees. B. SMALL BUSINESS CONCERN - By checking the appropriate box on the front of this form, the Vendor represents and certifies that it is a small business concern and all end items to be furnished will be manufactured or produced by a small business concern in the United States, its territories or possessions, Puerto Rico, or the Trust Territory of the Pacific Islands. C. SMALL DISADVANTAGED BUSINESS CONCERN - By checking the appropriate box on the front of this form, the Vendor represents and certifies that it is a small disadvantaged business concern. The Vendor represents and certifies that the Small Business Administration (SBA) has or has not made a determination concerning the Vendor's status as a small disadvantaged business concern. If the SBA has made such a determination the date of the determination was ___/___/___, and the Vendor certifies that it was found by the SBA to be socially and economically disadvantaged as a result of that determination and that no circumstances have changed to vary that determination, or it was not found by the SBA not to be socially and economically disadvantaged as a result of the determination, but circumstances which caused the determination have changed. NOTIFICATION - The Vendor agrees to notify Texas Instruments, before award, of any change in its status as a small disadvantaged business concern, occurring between the submission of this certification and contract award. PENALTY - The Vendor represents and certifies that the above information is true and understands that whoever for the purpose of securing a contract or subcontract under subsection (a) of section 1207 of Pub. L 99-661, misrepresents the status of any concern or person as a small business concern owned and controlled by a minority as described herein shall (i) be punished by imposition of a fine, imprisonment, or both; (ii) be subject to administrative remedies including suspension and disbarment; and (iii) be ineligible for participation in programs conducted under the authority of the Small Business Act. WOMEN-OWNED BUSINESS DEFINITION By checking the appropriate boxes on the front of this form, the Vendor represents that it is a Women Owned Small business concern. "Women-Owned" as used in this provision, means a small business that is at least fifty-one percent (51%) owned by a woman (women), who is a (are) U.S. citizen(s) and who also operate and control the business.
AFFIRMATIVE ACTION REPRESENTATION/NON-SEGREGATED FACILITIES
By checking the appropriate box on the front of this form, the Vendor represents that it has or has not filed all required compliance reports required by FAR 52.222-26 and representations indicating submission of required compliance reports signed by proposed subcontractors, will be obtained before subcontract awards.
A. "Segregated facilities," as used in this provision, means any waiting rooms, work areas, rest rooms and wash rooms, restaurants and other eating areas, time checks, locker rooms and other storage or dressing areas, parking lots, drinking fountains, recreation or entertainment areas, transportation, and housing facilities provided for employees, that are segregated by explicit directive or are in fact segregated on the basis of race, color, religion, or national origin because of habit, local custom, or otherwise.
B. By the submission of this form, the Vendor certifies that it does not and will not maintain or provide for its employees any segregated facilities at any of its establishments and that it does not and will not permit its employees to perform their services at any location under its control where segregated facilities are maintained. The Vendor agrees that a breach of this certification is a violation of the Equal Opportunity clause in the contract.
C. The Vendor further agrees that (except where it has obtained identical certifications from proposed subcontractors for specific time periods) it will: 1. Obtain identical certifications from proposed subcontractors before the award of subcontracts under which the subcontractor will be subject to the Equal Opportunity clause; 2. Retain the certifications in the files; and 3. Forward the following notice to the proposed subcontractors (except if the proposed subcontractors have submitted identical certifications for specific time periods):
[NOTICE TO PROSPECTIVE SUBCONTRACTORS OF REQUIREMENT FOR CERTIFICATIONS OF NON - SEGREGATED FACILITIES] A Certification of Non - segregated Facilities must be submitted before the award of a subcontract under which the subcontractor will be subject to the Equal Opportunity clause. The certification may be submitted either for each subcontract or for all subcontracts during a period (i.e. quarterly, semiannual, or annually). NOTE: The penalty for making false statements is prescribed in 18 U.S.C. 1001.
ANCIENT FOREST FIBER IN PRODUCTS PROVIDED
By checking the appropriate box on the front of this form, the Vendor certifies that a program to eliminate the use of ancient forest wood in derived products does not exist, has been started, or has been completed for all products supplied to or through the course of supplying services to Texas Instruments.
Environmental, Safety and Health Certification
By checking the appropriate box on the front of this form, Vendor certifies compliance with, and ensures that its employees, contractors, subcontractors and agents comply with, and provide all notices and other communications required under, all applicable local, state, federal and international laws, ordinances, rules, governmental or judicial orders, regulations and guidelines, including but not limited to the Occupational Safety and Health Act ("OSHA") and all environmental and public and employee health and safety laws (collectively "ESH Laws"). Additionally, the Vendor agrees to comply with the Federal Acquisition Regulations (FAR 52.223-1) regarding the clean air and water control acts.
This form is used as a Substitute W-9
(If a requester gives you a form other than Form W-9 to request your TIN, you must use the requestor's form if it is substantially similar to the Form W-9)
CERTIFICATION & PENALTIES Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding., or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding. Failure to furnish TIN If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect. Civil penalty for false information with respect to withholding If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty. Criminal penalty for falsifying Information Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment. Misuse of TINs If the requester discloses or uses TINs in violation of Federal law, the requester may be subject to civil and criminal penalties.
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