B-BBEE — B-BBEE Affidavit Template: B-BBEE Affidavit — QSE (General) (source: https://www.thedtic.gov.za/wp-content/uploads/BEE_Affidavit-QSE-Gen.pdf)
SWORN AFFIDAVIT – B-BBEE QUALIFYING SMALL ENTERPRISE - GENERAL
I, the undersigned,
Full name & Surname
Identity number
Hereby declare under oath as follows:
1. The contents of this statement are to the best of my knowledge a true reflection of the facts.
2. I am a Member / Director / Owner (Select one) of the following enterprise and am duly
authorised to act on its behalf:
Enterprise Name:
Trading Name (If
Applicable):
Registration Number:
Vat Number (If applicable)
Enterprise Physical
Address:
Type of Entity (CC, (Pty)
Ltd, Sole Prop etc.):
Nature of Business:
Definition of “Black As per the Broad-Based Black Economic Empowerment Act 53 of 2003 as
People” Amended by Act No 46 of 2013 “Black People” is a generic term which
means Africans, Coloureds and Indians –
(a) who are citizens of the Republic of South Africa by birth or
descent; or
(b) who became citizens of the Republic of South Africa by
naturalisation-
i. before 27 April 1994; or
ii. on or after 27 April 1994 and who would have been
entitled to acquire citizenship by naturalization prior to
that date;”
Definition of “Black “Black Designated Groups means:
Designated Groups”
(a) unemployed black people not attending and not required by law
to attend an educational institution and not awaiting admission
to an educational institution;
(b) Black people who are youth as defined in the National Youth
Commission Act of 1996;
(c) Black people who are persons with disabilities as defined in
the Code of Good Practice on employment of people with
disabilities issued under the Employment Equity Act;
(d) Black people living in rural and under developed areas;
(e) Black military veterans who qualifies to be called a military
veteran in terms of the Military Veterans Act 18 of 2011;”
3. I hereby declare under Oath that:
The Enterprise is ______________% Black Owned using the flow-through principle as per
Amended Code Series 100 of the Amended Codes of Good Practice issued under section 9
(1) of B-BBEE Act No 53 of 2003 as Amended by Act No 46 of 2013,
The Enterprise is ______________% Black Female Owned as per Amended Code Series 100
of the Amended Codes of Good Practice issued under section 9 (1) of B-BBEE Act No 53 of
2003 as Amended by Act No 46 of 2013,
The Enterprise is ______________% Black Designated Group Owned as per Amended Code
Series 100 of the Amended Codes of Good Practice issued under section 9 (1) of B-BBEE Act
No 53 of 2003 as Amended by Act No 46 of 2013,
Black Designated Group Owned % Breakdown as per the definition stated above:
Black Youth % = ______________%
Black Disabled % =______________%
Black Unemployed % =______________%
Black People living in Rural areas % = ______________%
Black Military Veterans % =______________%
Based on the Audited Financial Statements/ Financial Statements and other information
available on the latest financial year-end of _________________ (DD/MM/YYYY), the annual
Total Revenue was between R10,000,000.00 (Ten Million Rands) and R50,000,000.00 (Fifty
Million Rands),
Please confirm on the table below the B-BBEE level contributor, by ticking the applicable
box.
100% Black Owned Level One (135% B-BBEE procurement recognition level)
At Least 51% black owned Level Two (125% B-BBEE procurement recognition level)
4. I know and understand the contents of this affidavit and I have no objection to take the
prescribed oath and consider the oath binding on my conscience and on the owners of the
enterprise which I represent in this matter.
5. The sworn affidavit will be valid for a period of 12 months from the date signed by
commissioner.
Deponent Signature:
Date:
Commissioner of Oaths
Signature & stamp
Date:
Plant Breeders' Rights Act, 1976
