6100-1d EPA DBE Certification Application (Corporations)

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
Business Profile:

For Corporations

Name of applicant firm: _____________________________________________________________________
Name of President/Chief Executive Officer: _____________________________________________________
EIN:_______________________________________ 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 U.S. 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 the certifying entity:
_________________________________________________________________________________________
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: _____________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

EPA DBE Certification Application (EPA Form 6100-1d)
(Corporations)

Do you 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 6100-1d)
(Corporations)

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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

Other last
Names Used

U.S. Citizen
Y/N

Place of
Birth

Group
Membership

Sex
M/F

___________________

___________

________

___________

_______

_____

___________________

___________

________

___________

_______

_____

___________________

___________

________

___________

_______

_____

a)

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

_______________________________

________

________

_____

_______________________________

________

________

_____

_______________________________

________

________

_____

_______________________________

________

________

_____

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

EPA DBE Certification Application (EPA Form 6100-1d)
(Corporations)

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For this section, any individual 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 corporation 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 corporation and the equity in the individual(s) primary
residence.

EPA DBE Certification Application (EPA Form 6100-1d)
(Corporations)

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Name

Average 2-year
Income

Personal
Net Worth

Total
Assets

________________________________

______________

__________

_______

________________________________

______________

__________

_______

________________________________

______________

__________

_______

________________________________

______________

__________

_______

3.

Have any individual(s) listed in number 2 above 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 C-1: 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. Individual(s) 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. Individual(s) may also exclude any transfers to an immediate
family member if for educational, medical or essential support purposes.

4.

Each individual listed in number 2 above, certifies that because of racial and/or ethnic prejudice,
and/or cultural bias, his/her 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.

If more than one class of stock, provide information for each class:
Voting
a) Total number of shares authorized:
b) Total number of shares currently outstanding:

2.

Total
_____
_____

List all individuals, entities, and/or trusts, which have an ownership interest in the applicant firm.
Name

________________
3.

_____
_____

Non
Voting
______
______

Title

Voting

Ownership
Non-Voting

Percentage
Total

______

_____

____________

__________

Do disadvantaged individuals receive at least 51% of the annual distributions of dividends paid on
the stock of a corporate applicant firm? ___ Yes ___ No. If no, please explain and provide as
Attachment D-1.

4. Do disadvantaged individuals own 51% or more of each class of voting stock outstanding and 51% of
the aggregate of all stock outstanding? ___ Yes ___ No.

EPA DBE Certification Application (EPA Form 6100-1d)
(Corporations)

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5.

Will disadvantaged individuals receive 100% of the unencumbered value of each share of stock
owned in the event that the stock is sold? ___Yes ___ No. If no, please explain and provide as
Attachment D-2.

6.

If the corporation dissolves, will disadvantaged individuals receive at least 51% of the retained
earnings and 100% of the unencumbered value of each share of stock he or she owns?
___ Yes ___ No. If no, please explain and provide as Attachment D-3.

7.

Is ownership by any individual claiming disadvantaged status subject to conditions precedent,
conditions subsequent, executory agreements, voting trusts, shareholder agreements or other similar
arrangements, which may impact the unconditional ownership of such individuals? ___ Yes ___ No.
If yes, explain as Attachment D-4.

8.

Have there been any changes in ownership in the last year? ___ Yes ___ No. If yes, did the change in
ownership affect the disadvantaged status of your firm? Please explain as Attachment D-5.
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.
Name of Disadvantaged Owner

State of Residence

Percent Transferred

____________________________

_______

__________________

____________________________

_______

__________________

____________________________

_______

__________________

____________________________

_______

__________________

SECTION E
(All applicant firms must complete)
Control
1.

Disadvantaged individuals control the board of directors by virtue of the fact that (select only one
below):
____
a)
A single disadvantaged individual owns 100% of all the voting stock of the
applicant business.
____

b)
A single disadvantaged individual owns at least 51% of all voting stock, is on the
Board of Directors, and no super majority voting requirements exist for shareholders to
approve corporate actions.

____

c)
A single disadvantaged individual owns at least 51% of all voting stock, is on the
Board of Directors, and owns at least the percentage of voting stock needed to overcome
the super majority voting requirements which exist for shareholders to approve corporate
actions.

____

d)
More than one disadvantaged individual owns at least 51% of all voting stock, all
such individuals serve on the Board of Directors, no super majority voting requirements
exist for shareholders to approve corporation actions, and the disadvantaged

EPA DBE Certification Application (EPA Form 6100-1d)
(Corporations)

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shareholders can demonstrate they have made enforceable arrangements to permit one of
them to vote the stock of all as a block without holding a shareholder meeting.
____
e)
More than one disadvantaged individual owns at least 51% of all voting stock, all
such individuals serve on the Board of Directors, in total all own at least the percentage of voting stock
needed to overcome the existing super majority voting requirements which exist for shareholders to
approve corporate actions, and the disadvantaged individuals can demonstrate they have made
enforceable arrangements to permit one of them to vote the stock of all as a block without holding a
shareholder meeting.
OR
____
f)
The disadvantaged individual(s) control the Board of Directors through actual
numbers of voting directors.
____
2.

g)
The disadvantaged individual(s) control the Board of Directors through weighted
voting and such voting is permitted by applicable state law.

List the titles of all officers, directors, and key managers and the hours devoted by such individuals to
the management of the applicant business.
Name

Title

Hours

_____________________

__________

_______

_____________________

__________

_______

_____________________

__________

_______

_____________________

__________

_______

3.

Is the CEO, President or any disadvantaged full-time manager engaged in or planning to engage in
outside employment? ___ Yes ___ No. If yes, provide details as to the extent of outside employment
or other business dealings including daily hours of employment, location and explanation as to how
this outside employment does not conflict with the ability to manage and control the daily operations
of the applicant concern, provide as Attachment E-1.

4.

Have any of the nondisadvantaged individuals involved in the management of the applicant firm,
and/or stockholders, officers, directors or their immediate family members, had a prior business
relationship with any individual claiming disadvantaged status? This includes such relationships as
employer-employee, supervisor-employee, co-workers, investor-employee, etc. ___ Yes ___ No. If
yes, identify the person(s) and the type of business relationship, provide as Attachment E-2.

5.

Does any nondisadvantaged individual receive compensation in any form, including dividends, as a
director, officer, or employee that exceeds the compensation received by the disadvantaged President
or CEO? ____ Yes ____ No. If yes, provide the total compensation received by the President or CEO,
and the name(s) and the amount of the total compensation paid to the nondisadvantaged
individual(s). If any nondisadvantaged individual is more highly compensated, provide a statement
that justifies the need for the nondisadvantaged individual(s) to receive a higher compensation,
provide as Attachment E-3.

6.

Does the applicant firm operate in an industry that 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,
provide as Attachment E-4.

EPA DBE Certification Application (EPA Form 6100-1d)
(Corporations)

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7.

List the names and titles of all individuals who have access to the firm’s bank account.
Name

Title

________________________
________________________
________________________
________________________
________________________
8.

_______________________
_______________________
_______________________
_______________________
_______________________

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

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)

___ Yes
___ Yes
___ Yes
___ Yes
___ Yes

___ 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, provide as Attachment E-5.

EPA DBE Certification Application (EPA Form 6100-1d)
(Corporations)

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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 to determine 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 DBE Certification Form to this
address.
EPA DBE Certification Application (EPA Form 6100-1d)
(Corporations)

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