6100-2 DBE Program Subcontractor Participation Form

OMB Control No: ________
Approved:
________
Approval Expires: ________

Environmental
Protection Agency
Disadvantaged Business Enterprise Program
DBE Subcontractor Participation Form

NAME OF SUBCONTRACTOR1

PROJECT NAME

ADDRESS

CONTRACT NO.

TELEPHONE NO.

E-MAIL ADDRESS

PRIME CONTRACTOR NAME
Please use the space below to report any concerns regarding the above EPA-funded project (e.g., reason for
termination by prime contractor, late payment, etc.).
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRACT
ITEM NO.

ITEM OF WORK OR DESCRIPTION OF SERVICES RECEIVED FROM
THE PRIME CONTRACTOR

_________________________________
Subcontractor Signature

AMOUNT
SUBCONTRACTOR
WAS PAID BY PRIME
CONTRACTOR

______________________________________
Title/Date

Subcontractor is defined as a company, firm, joint venture, or individual who enters into an agreement
with a contractor to provide services pursuant to an EPA award of financial assistance.

1

EPA FORM 6100-2 (DBE Subcontractor Participation Form)

OMB Control No: ________
Approved:
________
Approval Expires: ________

Environmental
Protection Agency
Disadvantaged Business Enterprise Program
DBE Subcontractor Participation Form

The public reporting and recordkeeping burden for this collection of information is estimated to average fifteen (15)
minutes. Burden means the total time, effort, or financial resources expended by persons to generate, maintain,
retain, or 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 Subcontractor Participation Form to this address.

EPA FORM 6100-2 (DBE Subcontractor Participation Form)