Recertification Form

Thank you for your participation as a Florida Unique Abilities Partner. Your partnership demonstrates your dedication to providing employment and career opportunities to Floridians with Disabilities. Section 413.801, Florida Statutes requires, "After an initial designation as a Florida Unique Abilities Partner, a business entity must certify each year that it continues to meet the criteria for the designation. If the business entity does not submit the yearly certification of continued eligibility, the agency shall remove the designation. The business entity may elect to discontinue its designation status at any time by notifying the agency of such decision.

Business Information:
1. Business Name: *

2. First and last name of person submitting form: *

3. Email of person submitting form: *

4. Business FEIN: *

5. My business continues to meet the following qualifying criteria: * (Check all that apply)

The business employs at least one individual who has a disability. The employee(s) is a resident of the State of Florida and has been employed by the business for at least 9 months; or

The business has made contributions to local and national disabilityorganizations or contributions in support of individuals who have adisability. Contributions may be accomplished through financial or in-kind contributions, including employee volunteer hours. A businessentity with 100 or fewer employees must make a financial or in-kind contribution of at least $1,000, and a business entity with more than100 employees must make a financial or in-kind contribution of atleast $5,000; or

The business has established, or has contributed to the establishment of, a program that contributes to the independence of individuals who have a disability. A business entity with 100 or fewer employees must make a financial or in-kind contribution of at least $1,000 in the program, and a business entity with more than 100 employees must make a financial or in-kind contribution of at least $5,000; or

My business no longer qualifies.

6. I hereby attest that all information is true and accurate to the best of my knowledge. I confirm that our business continues to meet the eligibility criteria for the Florida Unique Abilities Partner Program. *

Type your full name to confirm and recertify.

Unique Abilities Partner Program
The Agency for Persons with Disabilities
4030 Esplanade Way, Suite 380
Tallahassee, FL 32311