6100-1c EPA DBE Certification Application (Partnerships)

Environmental Protection Agency

OMB Control No: ______
Approved:
______
Approval Expires: ______

EPA DBE Certification Application
For a Minority Business Enterprise (MBE)/Women-owned Business Enterprise (WBE)
Under EPA’s Disadvantaged Business Enterprise (DBE) Program
For Partnerships
Business Profile:
Name of applicant firm:______________________________________________________________________
Name of Managing Partner:__________________________________________________________________
EIN:___________________ Social Security Number _________________E-mail Address:_______________
Business Address:______________________________________________ County:______________________
City:_________________________________ State:_______________ Zip Code:________________________
Phone Number:___________________________ Fax Number:______________________________________
Mailing Address (if different than above):_________________________ County:_____________________
City:_________________________________ State:_______________ Zip Code:________________________
What is the firm’s 4 digit primary North American Industrial Classification (NAIC) code? ____________
Are you claiming disabled status? ____Yes ____No (i.e., a United States citizen who has permanent
or temporary physical or mental impairment that substantially limits one or more of your major life
activities.) If yes, please submit documentation substantiating such disability.
Is your firm at least 51% owned by a Disabled American? ____ Yes ____ No.
Is your firm certified by the Small Business Administration under its 8(a) Business Development
Program? ___ Yes ___ No. If yes, provide PRO-Net number: ______________________________________
Is your firm certified by the Small Business Administration under its Small Disadvantaged Business (SDB)
Program? ___ Yes ___ No. If yes, provide PRO-Net number: ____________________________________
Is your firm certified as a DBE by a Department of Transportation recipient? ___ Yes ___ No.
If yes, provide State(s) and ID number(s): ______________________________________________________
Is your firm certified by a State government, local government, Indian tribal government, or independent
private organization? ___ Yes ___ No. If yes, provide ID number and a contact point at the certifying
entity: ____________________________________________________________________________________

EPA DBE Certification Application (EPA Form 6100-1c)
(Partnerships)

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Has your firm ever been denied certification by a Federal agency, State government, local government,
Indian tribal government, or independent private organization? ___ Yes ___ No. If yes, provide a copy
of the prior determination of attempts to obtain certification: ____________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Does your firm have any other certification as a disadvantaged business entity, i.e., MBE, DBE, WBE, etc.?
___ Yes ___ No. If yes, provide State(s) and ID number(s): _______________________________________
In accordance with 13 CFR §124.103, designated group members are presumed to be socially disadvantaged.
Designated group members are individuals who hold themselves out to be and are identified by others as Black
Americans, Native Americans (American Indians, Eskimos, Aleuts, or Native Hawaiians), Hispanic Americans,
Subcontinent Asian Americans, Asian Pacific Americans, and any other groups designated by the Small
Business Administration (SBA). If an individual is claiming to be a member of a designated group, complete
Section A of this application. If an individual is not claiming to be a member of a designated group, complete
Section B of this application. All applicants must complete Sections C, D, and E of this application.

EPA DBE Certification Application (EPA Form 6100-1c)
(Partnerships)

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SECTION A

Eligibility Statement - Designated Group Members
Social Disadvantage
1.

Is your firm at least 51% owned by a U.S. citizen? ____ Yes ____ No. If your firm is not at least 51%
owned by a U.S. Citizen, stop here. You are not eligible to participate as a DBE under EPA’s DBE
Certification Program.

2.

List all individuals claiming disadvantaged status.

Name of Individual

Group
Membership

U.S. Citizen
Y/N

Other Last
Names Used

Place of
Birth

Sex
M/F

__________________________

___________

________

___________

_______

_____

__________________________

___________

________

___________

_______

_____

__________________________

___________

________

___________

_______

_____

2a. If you are a naturalized Citizen, please provide the following as Attachment A-1:
(a) naturalization number; (b) date of citizenship; and (c) county, state and court.

SECTION B

Eligibility Statement – Non Designated Group Members
1.

List all individuals claiming disadvantaged status:
Name of Individual

U.S. Citizen
Y/N

Race

Sex
M/F

_______________________________

________

________

_____

_______________________________

________

________

_____

_______________________________

________

________

_____

1a. If you are a naturalized Citizen, please provide the following as Attachment B-1:
naturalization number; (b) date of citizenship; and (c) county, state and court.

EPA DBE Certification Application (EPA Form 6100-1c)
(Partnerships)

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For this section, all individuals claiming social disadvantage must provide a separate response for
questions 3 and 4.

Social Disadvantage
2.

I, ____________________________________ have personally suffered social disadvantage based
on my identification as __________________________________.
(A claim of social disadvantage must include at least one objective feature that has
contributed to social disadvantage, such as race, ethnic origin, gender, physical handicap,
long-term residence in an environment isolated from the mainstream of American society, or
other similar causes not common to individuals who are not socially disadvantaged.)

3.

Document how your ability to compete in the free enterprise system has been impaired by such
things as inability to obtain adequate bonding, credit or financing; inability to obtain licenses or
leases; restriction of your market to certain racial, ethnic or social groups; underemployment or
unemployment, etc., as compared to others in the same or similar line of business who are not
socially disadvantaged. Provide as Attachment B-2.

4.

Attach a narrative describing how you personally experienced social disadvantage in
American society. When writing your narrative, be as specific and detailed as possible. Where
applicable, each statement of alleged discrimination should be supported by documented
evidence such as affidavits, denials of loan applications, denials of employment opportunities
(including non-selection for particular jobs, denials of promotions, or unequal work environment
or treatment), and documents to support any formal action taken by you because of alleged
discrimination. You must demonstrate how your identification, as described in the paragraph
above, has negatively impacted your entry into or advancement in business. You must address
disadvantage in education, employment, and business history, where applicable. Examples of
discrimination include, but are not limited to: unequal access to colleges or professional schools;
exclusion from professional or business associations; being denied educational honors or
recognition; experiencing discriminatory social pressure which discouraged you from pursuing a
professional or higher education or forced you into non-professional or non-business fields;
discrimination in employment opportunities or pay and fringe benefits; unequal access to
business credit or capital; and discrimination in the awarding, bidding process, or negotiating of
government or private sector contracts. Provide as Attachment B-3.

SECTION C

(All applicant firms must complete)
Economic Disadvantage
1.

Is the net worth of each individual(s) claiming disadvantaged status less than $750,000, excluding
ownership interest in the applicant firm and equity in the individual(s) primary residence?
____ Yes ____ No.

2.

For individual(s) claiming disadvantaged status, list your personal net worth, excluding the
ownership interest in the applicant firm and the equity in the individual(s) primary residence.

EPA DBE Certification Application (EPA Form 6100-1c)
(Partnerships)

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3.

Name

Average 2-year
Income

Personal
Net Worth

Total
Assets

________________________________

______________

__________

__________

________________________________

______________

__________

__________

________________________________

______________

__________

__________

Each individual listed in number 2 above, certifies that because of racial and/or ethnic prejudice,
and/or cultural bias, my ability to compete in the free enterprise system has been impaired due to
diminished capital and credit opportunities as compared to others in the same or similar line of
business that are not socially disadvantaged.

SECTION D

(All applicant firms must complete)
Ownership
1.

Provide the name, title, and percentage of ownership (class, if applicable) for each partner of the firm.
Does the partnership agreement reflect the ownership of each partner? ____ Yes ____ No.
Name

Title

Ownership Percentage

______________________

____________________

___________________________

______________________

____________________

___________________________

______________________

____________________

___________________________

______________________

____________________

___________________________

2.

Has there been any changes in ownership in the last year? ____ Yes ____ No. If yes, did ownership
affect the disadvantaged status of your firm? Please explain as Attachment D-1.

3.

For community property residents only. If you are a married disadvantaged owner, and your spouse
is not disadvantaged, please complete the chart below, and provide evidence that you have a majority
interest in the business as Attachment D-2.
Name of Disadvantaged Partner

State

Percent Transferred

______________________

____________________

_____________________

______________________

____________________

_____________________

______________________

____________________

_____________________

______________________

____________________

_____________________

EPA DBE Certification Application (EPA Form 6100-1c)
(Partnerships)

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4.

Has any individual(s) claiming disadvantaged status transferred any assets within two years, in full
or in part, to a spouse or any other person or entity, including a trust? ___ Yes ___ No. If yes,
provide the following information as Attachment D-3: the date of transfer; to whom the assets were
transferred; amount paid for the assets; and the market value of the assets at the time of transfer.
Individuals may exclude assets transferred to an immediate family member that are consistent with
the customary recognition of special occasions, such as birthdays, graduations, anniversaries and
retirements. Individuals may also exclude any transfers to an immediate family member if for
educational, medical or essential support purposes.

SECTION E
(All applicant firms must complete)

Control
1.

List the name(s) of all Partners:
Name

Limited/General

___________________________________

_____________________________

___________________________________

_____________________________

___________________________________

_____________________________

___________________________________

_____________________________

2.

Are partnership decisions determined by general partners? If no, explain as Attachment

3.

Is a general partner, or any disadvantaged full-time manager engaged in or plan to engage in outside
employment? ___ Yes ___ No. If yes, explain as Attachment E-2.

4.

Have any of the nondisadvantaged individuals involved in the management of the applicant firm,
partners, or their immediate family members, had a prior business relationship with any individual
claiming disadvantage status? This includes such relationships as employer-employee, supervisoremployee, co-workers, investor-employee, etc. ___ Yes ___ No. If yes, identify the person(s) and the
type of business relationship as Attachment E-3.

5.

List the total compensation from the applicant firm of all partners and/or key managers of the firm.
(If necessary, provide additional information as Attachment E-4).
Name/Title

Compensation from applicant firm
(includes salaries, bonuses, etc.)

_________________________________

___________________________________

________________________________

___________________________________

________________________________

___________________________________

________________________________

___________________________________

EPA DBE Certification Application (EPA Form 6100-1c)
(Partnerships)

E-1.

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6.

7.

8.

Does the applicant firm operate in an industry which requires bonding or professional licenses?
___ Yes ___ No. If yes, identify the qualifying individual(s) for the critical licenses, general
indemnity agreement, permits, certifications, and bonding required to operate the applicant firm as
Attachment E-5.
List the names of all individuals who have access to the firm’s bank account.
Name

Title

______________________________

_____________________________

______________________________

_____________________________

______________________________

_____________________________

Does any individual(s), (other than the individual(s) claiming disadvantaged status) or entities
provide:
a)
b)
c)
d)
e)
f)

Financial support to the applicant firm?
Subcontracts, Joint Ventures or Teaming Arrangements?
Office space (rent or leased).
Equipment (rent or leased).
Employees (other than from employment agencies).
Provide business bank account.

___
___
___
___
___
___

Yes ___
Yes ___
Yes ___
Yes ___
Yes ___
Yes ___

No
No
No
No
No
No

If you answered yes to any of the above, please provide specific details (i.e., names, titles, copies
of agreements, leases, etc.) of such arrangements as Attachment E-6.

EPA DBE Certification Application (EPA Form 6100-1c)
(Partnerships)

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Each person signing below:
1.

Certifies that the information provided with regard to my social and economic disadvantaged
status is true, accurate and complete to the best of my knowledge and belief.

2.

Certifies that the information provided with regard to my ownership and control status is true,
accurate and complete to the best of my knowledge and belief.

3.

Certifies that the information provided with regard to my status as a United States citizen is true,
accurate and complete to the best of my knowledge and belief.

4.

Certifies that the information provided with regard to my individual disadvantaged status is true,
accurate and complete to the best of my knowledge and belief.

5.

Certifies that the information provided, including that shown on documents accompanying this
application, is true, accurate and complete to the best of my knowledge and belief.

6.

Acknowledges that EPA, at its discretion, may give the information submitted to Federal, state
and local agencies for determining violations of law.

7.

Acknowledges that EPA’s approval of an application does not affect the Government’s right to
pursue criminal prosecution for incorrect or incomplete information given on the application
form, even if correct information has been included in other materials submitted to EPA.

Name
________________________

SSN
_______________________

Date
______________________

________________________

_______________________

______________________

________________________

_______________________

______________________

The public reporting and recordkeeping burden for this collection of information is estimated to average
three (3) hours. Burden means the total time, effort, or financial resources expended by persons to
generate, maintain, retain, disclose or provide information to or for a Federal agency. This includes the
time needed to review instructions; develop, acquire, install, and utilize technology and systems for the
purposes of collecting, validating, and verifying information, processing and maintaining information,
and disclosing and providing information; adjust the existing ways to comply with any previously
applicable instructions and requirements; train personnel to be able to respond to a collection of
information; search data sources; complete and review the collection of information; and transmit or
otherwise disclose the information. An agency may not conduct or sponsor, and a person is not required
to respond to, a collection of information unless it displays a currently valid OMB control number.
Send comments on the Agency’s need for this information, the accuracy of the provided burden
estimates, and any suggested methods for minimizing respondent burden, including the use of
automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental
Protection Agency (2822), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB
control number in any correspondence. Do not send the completed EPA DBE Certification Form to this
address.

EPA DBE Certification Application (EPA Form 6100-1c)
(Partnerships)

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