6100-1f EPA DBE Certification Application (Tribally Owned Busine

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

Environmental Protection Agency

EPA DBE Certification Application
For a Minority Business Enterprise (MBE)/Women-owned Business Enterprise (WBE)
Under EPA’s Disadvantaged Business Enterprise (DBE) Program
Tribally Owned Businesses
Name of Indian tribe:_______________________________________________________________
Address of tribe:___________________________________________________________________
Name of wholly-owned
Subsidiary (if applicable):____________________________________________________________
Address of wholly-owned
Subsidiary:_______________________________________________________________________
Name of applicant firm:____________________________________________________________
Applicant concern is:

Corporation

Limited Liability Company

Partnership

Name of President/Managing Member/Managing Partner:_______________________________
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?
__________________________________________________________________________________
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): _________________________________________

EPA DBE Certification Application (EPA Form 6100-1f)
(Tribally Owned Businesses)

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 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
explanation/documentation:____________________________________________________________
_____________________________________________________________________________________
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): ________________________________
Is the applicant firm a for profit business? ___ Yes ___ No.
Do the tribe’s articles of incorporation/ articles of organization/ partnership agreement contain
express sovereign immunity waiver language or a “sue and be sued” clause which designates
United States Federal Courts to be a competent jurisdiction for all matters relating to EPA’s DBE
Program? ___ Yes ___ No. If yes, provide a complete copy of the documentation as attachment
D-3.

EPA DBE Certification Application (EPA Form 6100-1f)
(Tribally Owned Businesses)

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Business Eligibility

SECTION A
Social Disadvantage
1.

An Indian tribe that meets the following criteria is considered socially disadvantaged:
Indian tribe means any Indian tribe, band, nation, or other organized group or community of
Indians which is recognized as eligible for the special programs and services provided by the
United States to Indians because of their status as Indians, or is recognized as such by the
State in which the tribe, band, nation, group or community resides.
Provide documentation that the applicant entity meets these criteria as Attachment A-1.

2.

Provide copies of the tribe’s articles of incorporation and bylaws as filed with the organizing
or chartering authority, or similar documents needed to establish and govern a non-corporate
legal entity as Attachment A-2.

SECTION B
Economic Disadvantage
1.

Has the tribe previously established economic disadvantage to qualify as DBE?
___ Yes ___ No. If yes, provide documentation to verify disadvantaged status as Attachment
B-1.
If no, respond to the following questions as Attachment B-2:
a)
b)
c)
d)
e)
f)
g)

What is the number of tribal members on tribal rolls as of the date of application?
What is tribe’s present unemployment rate?
What is the per capita income of tribal members excluding judgment awards?
What is the percentage of the local Indian population below the poverty level?
What is the total tribal income for the applicant tribe?
What are the tribe’s assets as disclosed in a tribal financial statement?
Provide a list of all wholly or partially owned tribal enterprises or affiliates and
the primary industry classification of each. The listing should include the
members of the tribe who manage or control such enterprises by serving as
officers or directors.

2. The Indian Tribe must also submit the following documentation to substantiate a claim of
economic disadvantage:
a) A copy of all governing documents such as the tribe’s constitution or business
charter.
b) Evidence of its recognition as a tribe eligible for the special programs and
services provided by the United States or by its state of residence.

EPA DBE Certification Application (EPA Form 6100-1f)
(Tribally Owned Businesses)

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SECTION C
Ownership
Corporations Only:
1.

Does the tribe firm own at least 51% of the voting stock? ____ Yes ____ No. Please provide
documentation as attachment C-1.

2.

Does the tribe own at least 51% of the aggregate if all classes of stock? ___ Yes
Please provide documentation as attachment C-2.

3.

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:

_____
_____

___ No.

Non- Total
Voting
______ ______
______ ______

Non-Corporate Entities Only:
4.

Does the tribe own at least 51% interest in the firm? ___ Yes ___ No. Please provide
documentation as attachment C-3.

5.

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

_____
_____

Non- Total
Voting
______ _____
______ _____

For Corporate and Non-Corporate Entities:
6. Does the tribe currently own 51% or more of another firm under the same primary NAIC
code? ___ Yes ___ No.
7. Within the last two years has the tribe owned 51% or more of another firm under the same
primary NAIC code as the applicant? ___ Yes ___ No.

SECTION D
Control and Management
1. Are the management and daily business operations of the tribe controlled by the tribe through
one or more disadvantaged individual members who possess sufficient management
experience of an extent and complexity to run the concern? ___Yes ___No. If yes, provide
documentation to verify tribal membership and management competency as Attachment D-1.

EPA DBE Certification Application (EPA Form 6100-1f)
(Tribally Owned Businesses)

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2.

Is the management of the tribe controlled by committees, teams, Boards of Directors, or one
or more members of an economically disadvantaged tribe? ___ Yes ___ No. Please provide
documentation as attachment D-2.
Management may be provided by non-tribal members if it is determined that such
management is required to assist the concern’s development, provided that the tribe will
retain control of all management decisions common to Boards of Directors, including
strategic planning, budget approval and the employment and compensation of officers.
However, a written management development plan must exist which shows how
disadvantaged tribal members will develop managerial skills sufficient to manage the
concern or similar tribally-owned concerns in the future.

3.

Are members of the management team, business committee members, officers, and directors
engaged in any outside employment or other business interests which conflict with the
management of the tribe? ___ Yes ___ No.

4.

List the titles of all officers, directors, management members, partners and key managers and
the hours devoted, by such individual(s) to the management of the tribe.

5.

Name

Title

Hours

____________________________

_______________________________

__________

____________________________

_______________________________

__________

____________________________

_______________________________

__________

____________________________

_______________________________

__________

List the names of all individuals who have access to the tribe’s bank account.
Name
___________________________

Title
__________________________

__________________________

__________________________

__________________________

__________________________

__________________________

__________________________

EPA DBE Certification Application (EPA Form 6100-1f)
(Tribally Owned Businesses)

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Each person signing below:
1.

Certifies that the information provided with regard to the applicant firm’s social and
economic disadvantaged status is true, accurate, and complete to the best of his/her
knowledge and belief.

2.

Certifies that the information provided with regard to the applicant firm’s ownership and
control status is true, accurate, and complete to the best of his/her knowledge and belief.

3.

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

4.

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

5.

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

6.

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 6100-1f)
(Tribally Owned Businesses)

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