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Assurance Of Compliance For Nondiscrimination (United States)

This is a Small Business Administration (SBA) form to assure compliance of nondiscrimination. The form provided here is simply a sample of what the actual Form 652 looks like.

U.S. SMALL BUSINESS ADMINISTRATION
ASSURANCE OF COMPLIANCE FOR NONDISCRIMINATION


___________________________ Applicant/Licensee/Recipient/Subrecipient, (hereinafter referred to as applicant) in consideration of Federal financial assistance from the Small Business Administration, herewith agrees that it will comply with the nondiscrimination requirements of 13 CFR parts 112, 113, and 117, of the Regulations issued by the Small Business Administration (SBA).

13 CFR Parts 112, 113 and 117 require that no person shall on the grounds of age, color, handicap, marital status, national origin, race, religion or sex, be excluded from participation in, be denied the benefits of or otherwise be subjected to discrimination under any program or activity for which the applicant received Federal financial assistance from SBA.

Applicant agrees to comply with the record keeping requirements of 13 CFR 112.9, 113.5, and 117.9 as set forth in SBA Form 793, "Notice to New SBA Borrowers", to permit effective enforcement of 13 CFR 112, 113 and 117. Such record keeping requirements have been approved under OMB Number 3245-0076. Applicant further agrees to obtain or require similar Assurance of Compliance for Nondiscrimination from subrecipients, contractors/subcontractors, successors, transferees and assignees as long as it/they receive or retain possession of any Federal financial assistance from SBA. In the event the applicant fails to comply with any provision or requirements of 13 CFR Parts 112, 113 and 117, SBA may call, cancel, terminate, accelerate repayment or suspend any or all Federal financial assistance provided by SBA.

Executed the _______________________ day of ____________, 20____

Name Address & Phone No. of Applicant

Street ___________________________

City ___________________________

State ___________________________

Zip ___________________________

Phone Number ___________________________

By ___________________________
Typed Name & Title of Authorized Official

___________________________
Signature of Authorized Official

Corporate Seal


Name Address & Phone No. of Subrecipient

Street ___________________________

City ___________________________

State ___________________________

Zip ___________________________

Phone Number ___________________________

By ___________________________
Typed Name & Title of Authorized Official

___________________________
Signature of Authorized Official


Corporate Seal

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