BBBEE Affidavit Template

Company Letterhead (for physical document)

{{company_name}}

{{company_address}}

Phone: {{phone}}

Email: {{email}}

Website: {{website}}

BBBEE SWORN AFFIDAVIT - B-BBEE EXEMPTED MICRO ENTERPRISE / QUALIFYING SMALL ENTERPRISE

I, the undersigned,

Full Name: {{deponent_full_name}}

Identity Number: {{deponent_id_number}}

being a duly authorised representative of:

Enterprise Name: {{enterprise_name}}

Enterprise Registration No.: {{enterprise_registration_number}}

Enterprise Physical Address: {{enterprise_physical_address}}

hereby declare under oath as follows:

Sworn Statement

1. I am duly authorised to make this affidavit on behalf of the above-mentioned enterprise.

2. The enterprise is a/an (tick one):

[ ] Exempted Micro Enterprise (EME)

[ ] Qualifying Small Enterprise (QSE) with less than 51% black ownership

3. The annual total revenue of the enterprise is (tick one):

[ ] Below R10 million (for EME)

[ ] Between R10 million and R50 million (for QSE)

4. The enterprise has the following black ownership percentage:

Black Owned: {{black_ownership_percentage}}%

Black Female Owned: {{black_female_ownership_percentage}}%

5. I am aware that the aforesaid information is to be used for the purpose of confirming the B-BBEE status of the enterprise.

6. I understand that any false statement made in this affidavit is punishable by law.

B-BBEE Status and Recognition Level

Based on the above, the enterprise’s B-BBEE Status Level is:

EME Specific Declarations (if applicable)

If an EME, the enterprise is automatically a Level 4 B-BBEE contributor. If the EME is at least 51% Black Owned, it is a Level 2 B-BBEE contributor. If the EME is 100% Black Owned, it is a Level 1 B-BBEE contributor.

QSE Specific Declarations (if applicable)

If a QSE with less than 51% black ownership, the enterprise is a Level 4 B-BBEE contributor. If the QSE is at least 51% Black Owned, it is a Level 2 B-BBEE contributor. If the QSE is 100% Black Owned, it is a Level 1 B-BBEE contributor.

Supporting Documentation (Optional but Recommended)

A copy of the latest financial statements or management accounts confirming the annual turnover is attached hereto as Annexure 'A'.

COMMISSIONER OF OATHS

I certify that the deponent has acknowledged that he/she knows and understands the contents of this affidavit, that it is true and correct to the best of his/her knowledge and belief and that no part of it is false and that he/she has no objection to taking the prescribed oath, and that the oath was taken and the signature appended in my presence.

Before me,

___________________________________

COMMISSIONER OF OATHS

Full Names: {{commissioner_full_name}}

ID Number: {{commissioner_id_number}}

Designation: {{commissioner_designation}}

Physical Address: {{commissioner_address}}

Date: {{commissioner_date}}

Place: {{commissioner_place}}

Signature Block

___________________________________

DEPONENT (Signature)

Date: {{date}}

Place: {{place}}