|
SERVICE-CONNECTED DISABILITY RENEWAL STATEMENT
812B (New 4/01)
Department of General Services, Procurement Division
Office of Sm all Business Certification and Resources (OSBCR)
707 3rd Street, 1st Floor, Room 400, West Sacramento, CA 95605
(916) 375-4940 OSBCR REF #
The "Service-Connected Disability Renewal Statement" (812B) may be used in place of an Award of Entitlement letter when the following criteria are met:
- Your firm must be currently certified with the Office of Small Business Certification and Resources(OSBCR).
- A valid Award of Entitlement letter from the U.S. Department of Veteran Affairs or the U.S. Department of Defense must already be on file with the OSBCR for each qualifying disabled veteran.
- Each qualifying disabled veteran's service-connected disability rating has not changed since their most recently submitted Award of Entitlement letter to the OSBCR.
If your firm does not meet the above criteria, you must submit an Award of Entitlement letter for each qualifying disabled veteran. The entitlement letter must have the following specifications:
- The letter must be from the U.S. Department of Veteran Affairs or the U.S. Department of Defense.
- The letter must be dated within six (6) months of the OSBCR receiving your submitted DVBE certification renewal.
- The letter must certify or declare a "service-connected" disability rating of at least 10%.
To obtain an Award of Entitlement letter, you may call the U.S. Department of Veterans Affairs at 1-800-827-1000.
Instructions: Your qualifying disabled veteran must complete and sign the statement below and return it to the OSBCR with the rest of your DVBE certification renewal package. A separate statement must be completed by each of your firm's qualifying disabled veterans. (See above criteria.)
By my signature below, I________________________________ certify under penalty of perjury under the laws of the
Print Qualifying Disabled Veteran's Full Name
State of California that my disabled veteran service-connected disability rating is____________ %
Disability Rating
This disability rating has not changed since the submittal of my most recent Award of Entitlement letter to the OSBCR.
Please Sign and Date below
Qualifying Disabled Veteran's Signature
|
Date |
Applicant Firm's Name
|
OSBCR REF # | |
