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SECTION 3 BUSINESS AFFIDAVIT 1 . Company Name: 2 . Address: 3 . Business Structure: corporation partnership sole proprietorship joint venture 4. Type of business (i.e. house painting, accounting): TYPE OF SECTION 3 BUSINESS CONCERN Yes No 1. Is the Company a Section 3 Business Concern as defined below? a. Business is 51%or more owned by Section 3 residents*; or b. At least 30% of the business’s permanent, full-time employees are currently Section 3 residents, or within 3 years of the date of first employment with the firm were Section 3 residents; or c. Business provides evidence of a commitment to award more than 25% of the dollar amount of all subcontracts to businesses that fall within or above (provide list of subcontracted Section 3 businesses and subcontract amount): 2. Has the Company been selected to carry out any HUD YouthBuild Program? *A Section 3 Resident is 1) a Salem Housing Authority resident; or 2) a Salem resident whose total family income does not exceed 80% of the median income for the area as per the HUD local income limits; or 3) a resident of the Boston Metropolitan Statistical Area whose total family income does not exceed 80% of the median income for the area as per the HUD local income limits. VERIFICATION Please attached the company’s current payroll registry highlighting the staff meeting the Section 3 requirements. In addition, each potential Section 3 staff member must complete and submit the Section 3 Resident Certification. The Company hereby agrees to provide, upon request, any additional documents needed to verify the information provided above. Section 3 Business Certifications are valid for one year. Under penalty of perjury, I certify that I am the (Title) of the Company, that I am authorized by the Company to execute this affidavit on its behalf, that I have personal knowledge of the certification made in this affidavit and that the same are true. Name: (Printed) (Signature) COMMONWEALTH OF MASSACHUSETTS Essex, ss. On this day of , 20__ before me, the undersigned Notary Public, personally appeared , proved to me through satisfactory evidence of identification, which were , to be the person whose name is signed on the preceding or attached document in my presence. , Notary Public My Commission Expires Submit to the Dept. of Planning & Community Development, 98 Washington St., Salem, MA 01970 For Community Development Office Use Only Based on the documentation provided, this business has been verified a Section 3 Business located within the BMSA: Yes By: Date: