Get FDA 3602 2019-2023
1001 and other applicable federal statutes. Signature of person making this Small Business Certification Request must be signed by the person identified in item Date of this Small Business Certification Request MM/DD/YYYY FORM FDA 3602 8/18 Page 1 of 2 EF a. Name of Affiliate b. Taxpayer ID Number c. Gross Receipts or Sales Total Gross Receipts or Sales of All Affiliates sum of lines 1 through 15 sum of lines 16 and 17 PRIVACY ACT NOTICE This notice is provided pursuant to the Privacy Act of 1974 5 U.S.C. 552a. The collection of this information is authorized by 21 U.S.C. 379i and 379j. FDA will use the information to assess qualification as a small business collect and process user fee payments and facilitate debt collection under the Debt Collection Improvement Act. OMB Number 0910-0508 DEPARTMENT OF HEALTH AND HUMAN SERVICES Food and Drug Administration Expiration Date June 30 2019 PRA Statement See next page. MDUFA SMALL BUSINESS CERTIFICATION REQUEST Application for FY 20 For a Business Headquartered in the United States FY- October 1 through September 30 Section I Information about the Business Requesting Small Business Status 1. Name of business requesting MDUFA Small Business status 2. Taxpayer Identification Number 2a* Organization ID Number Org ID 3. Address where business is physically located 5. Your telephone number include area code 4. Name of person making this Small Business Certification Request 6. Your mailing address 7. Your email address Check if same as item 3. 8. What is your relation Title to the business claiming MDUFA Small Business status 9. Have you listed all of the business s affiliates in Section II of this form Check one response Yes This business has no affiliates. 10. Complete sign and date the following Certification I certify that has no affiliates and reported gross receipts or sales of no more than 100 000 000 on its most recent Federal U*S* income tax return* I have attached a true and accurate copy of the business s most recent Federal U*S* income tax return* has only the affiliates listed in this Certification and together with those affiliates reported total gross receipts or sales of no more than 100 000 000 for the most recent tax year. I have attached a true and accurate copy of the entity s most recent Federal U*S* income tax return and a true and accurate copy of the most recent Federal U*S* income tax return or an Foreign Small Business Certification for each of the entity s affiliates. I further certify that to the best of my knowledge the information I have provided in this Small Business Certification Request is complete and accurate. I understand that submission of false information may subject me to criminal penalties under 18 U*S*C. 1001 and other applicable federal statutes. Signature of person making this Small Business Certification Request must be signed by the person identified in item Date of this Small Business Certification Request MM/DD/YYYY FORM FDA 3602 8/18 Page 1 of 2 EF a* Name of Affiliate b.
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